Medical history

HEALTH INFORMATION:
Last____________________First_______________ Date_______ 321-751-7775
MEDICAL HISTORY
1. Are you experiencing any medical problem now? ______________________________________________________
2. Are you currently taking any medications, drugs, pills, or nutritional supplement? Please list ____________________ _____________________________________________________________________________________________ 3. Are you currently or have you ever taken bisphosphonates (ex: Fosamax, Didronel, Aredia)? ____________________ 4. Are you allergic or have you reacted adversely to: (check those that apply)  Metals, if so which ______________________  Other _____________________________________ 5. Please describe your general health:  Excellent  Good  Fair  Poor 6. Do you use any tobacco products?  No  Yes If yes, what and how much per day?________________________ 7. Name of your Physician:_________________________________________ Phone No.________________________ 8. Have you been hospitalized in the past 5 years? If yes, please explain._____________________________________ _____________________________________________________________________________________________ PLEASE CHECK ANY OF THE FOLLOWING WHICH YOU HAVE HAD OR HAVE AT PRESENT:

 Heart Failure
 Anemia
 Radiation Therapy
 Liver disease
 Heart disease or Attack
 Stroke
 Chemotherapy
 Blood Transfusion
 Angina Pectoris
 Kidney Trouble
(Cancer, Leukemia)
 Drug Addiction
 High Blood Pressure
 Ulcers
 Arthritis
 Hemophilia
 Heart Murmur
 Osteoporosis
 Rheumatism
 Venereal Disease
 Rheumatic Fever
 Emphysema
 Cortisone or Steroid
 Cold Sore/Fever Blisters
 Congenital Heart Lesions
 Active Tuberculosis (TB)
 Epilepsy or Seizures
 Mitral Valve Prolapse
 Asthma
 Glaucoma
 Fainting or Dizzy Spells
 Artificial Heart Valve
 Hay Fever
 Pain in Jaw Joints
 Nervousness
 Heart pacemaker
 Sinus Trouble
 HIV Positive (AIDS)
 Psychiatric Treatment
 Heart surgery
 Allergies or Hives
 Hepatitis A (Infectious)
 Sickle Cell Disease
 Joint (Hip, Knee)
 Diabetes
 Hepatitis B (serum)
 Bruise or bleed easily
Replacement
 Thyroid Disease
 Hepatitis C
 Cosmetic Surgery
Patient signature:
DENTAL HISTORY
1. What type of dental care are you most interested in? 6. Have you had dental treatment recommended to you that you haven’t completed? If so, why not? _________  Maintenance Care (patchwork treatment) _________________________________________  Incremental Care (developing and prioritizing a long  Complete Care (optimal treatment without delay)  Fillings  Extractions  Root Canals  Caps or Crowns  Fixed Bridges  Removable Bridges  Treatment of gum disease  Dentures  Implants  2. When did you last have dental treatment?________ Orthodontics  Cosmetic Bonding or Laminates  TMJ What was done?____________________________ Bite Adjustment  Other: ________________________ Name of dentist:____________________________ 8. Please check the following that are applicable: Due to HIPAA privacy regulations, you must request
 Teeth are sensitive to hot, cold, or pressure x-ray transfer yourself. Please ask for instructions.
 Gums bleed at times  Food wedges between teeth 3. Why are you seeking dental care now?__________ _________________________________________ 4. Are you having discomfort or complaints at this time? If so, please explain:_________________________  No  Slightly  Moderately  Very 5. If you could change anything about your mouth, what would that be? _____________________________ 10. What can we do to help you be more comfortable?____ ______________________________________________ _________________________________________________

Source: http://cisserver.com/smile/wp-content/uploads/2013/10/MEDICAL-HISTORY.pdf