MEDICAL HISTORY FORM Patient Name Date of birth Name of Family Physician PH# Treating Specialist(s) and their specialty PH2# Most recent physical examination Purpose How would you rate your general overall health Excellent Good Fair Poor Hospitalization for illness or injury Yes No An allergic or bad reaction to any of the following aspirin, ibuprofen, acetaminophen, codeine penicillin, sulfa or other antibiotics sedatives (sleeping pills) codeine or other narcotics iodine local anesthetic fluoride metals (nickel,gold,silver,mercury,_______________) latex foods/flavours/pigments environmental(i.e.; hay fever) other Swollen ankles, feet, hands Yes No Heart problems, or cardiac stent within last 6 months Yes No Angina or chest pain Yes No History of infective endocarditis Yes No Artificial heart valve, repaired heart defect (PFO) Yes No Pacemaker or implantable defibrillator Yes No Orthopedic implant (joint replacement) Yes No Rheumatic or scarlet fever Yes No High or low blood pressure A stroke (taking blood thinners) Yes No Anemia or other blood disorder Yes No Abnormal bruising or bleeding Yes No Pneumonia, emphysema, shortness of breath Yes No Asthma Yes No Tuberculosis, measles, chicken pox Yes No Sleep apnea, snoring or sinus problems Yes No Kidney disease, dialysis Yes No Liver disease Yes No Jaundice Yes No Thyroid, parathyroid disease, calcium deficiency Yes No Hormone deficiency Yes No High cholesterol or taking statin drugs Yes No Diabetes Type Stomach troubles(i.e.; ulcers) Yes No Digestive or eating disorders Osteoporosis/osteopenia (taking bisphosphonates) Yes No Autoimmune disease (i.e.lupus,rheumatoid arthritis) Yes No Glaucoma or eye surgery Yes No Contact lenses, hearing aid(s) Yes No Head or neck injuries Yes No Epilepsy, convulsions (seizures), fainting, dizzy spells Yes No Neurologic disorders (ADD/ADAH, prion disease) Yes No Viral infections and cold sores Yes No STI/STD/HPV (i.e.; Syphilis, Gonorrhea) Yes No Hepatitis (Type) HIV/AIDS Yes No Tumor(s), abnormal growth(s) Yes No Cancer of any type Radiation therapy Yes No Chemotherapy, immunosuppressive medication for what condition Yes No Emotional difficulties, anxiety, depression Yes No Psychiatric treatment Yes No Alcohol/recreational drug use Yes No Drug or alcohol dependency Yes No Steroid therapy Yes No Presently being treated for any other illness Yes No Often feel exhausted or fatigued Yes No Experiencing frequent headaches Yes Smoke(d), use(d) smokeless tobacco or chewing tobacco or cigarettes per day Currently pregnant or breast feeding Yes No Taking birth control medication Yes No Please describe any current medical treatment, impending surgery or other treatment or condition that is not listed above that may affect your dental treatment. (i.e. Botox, collagen injections) Drug 1 Purpose for drug 1 Drug 2 Purpose for drug 2 Drug 3 Purpose for drug 3 Patient’s Signature Patient’s Signature Date Doctor’s Signature Doctor’s Signature Date ASA BP PULSE RATE Submit
