Patient Name

Nickname

Age

Name of Physician/and their specialty

Most recent physical examination

Purpose

Do you have or have you ever had:

Hospitalization for illness or injury

Yes

No

An allergic or bad reaction to any of the following:

Yes

No

aspirin, ibuprofen, acetaminophen, codeine

penicillin

erythromycin

tetracycline

sulfa

local anesthetic

fluoride

chlorhexidine (CHX)

iodine

metals (nickel, gold, silver, etc.)

If metals, please specify

latex

nuts

fruit

milk

red dye

other

If other, please specify

Heart problems, or cardiac stent within the last six months

Yes

No

History of infective endocarditis

Yes

No

Artificial heart valve, repaired heart defect (PFO)

Yes

No

Pacemaker or implantable defibrillator

Yes

No

Orthopedic or soft tissue implant (e.g joint replacement, breast implant)

Yes

No

Heart murmur, rheumatic or scarlet fever

Yes

No

Heart murmur, rheumatic or scarlet fever

Yes

No

A stroke (taking blood thinners)

Yes

No

Anemia or other blood disorder

Yes

No

Prolonged bleeding due to a slight cut (or INR > 3.5)

Yes

No

Pneumonia, emphysema, shortness of breath, sarcoidosis

Yes

No

Chronic ear infections, tuberculosis, measles, chicken pox

Yes

No

Breathing problems (e.g. asthma, stuffy nose, sinus congestion)

Yes

No

Sleep problems (e.g. sleep apnea, snoring, insomnia, restless sleep, bedwetting)

Yes

No

Kidney Disease

Yes

No

Liver Disease or jaundice

Yes

No

Vertigo (e.g. ”the room is spinning”)

Yes

No

Thyroid, parathyroid disease, or calcium deficiency

Yes

No

Hormone deficiency or imbalance (e.g. poly cystic ovarian syndrome)

Yes

No

High cholesterol or taking statin drugs

Yes

No

Diabetes

Yes

No

If diabetes, please specify

Stomach or duodenal ulcer

Yes

No

Digestive or eating disorders (e.g. celiac disease, gastric reflux, bulimia, anorexia)

Yes

No

Osteoporosis/osteopenia or ever taken anti-resorptive medications (e.g. bisphosphonates)

Yes

No

Arthritis or gout

Yes

No

Autoimmune disease (e.g. rheumatoid arthritis, lupus, scleroderma)

Yes

No

Glaucoma

Yes

No

Contact Lenses

Yes

No

Neck Injuries

Yes

No

Epilepsy, convulsions (seizures)

Yes

No

Neurologic disorders (e.g. Alzheimer’s disease, dementia, prion disease)

Yes

No

Viral infections and cold sores

Yes

No

Any lumps or swelling in the mouth

Yes

No

Hives, skin rash, hay fever

Yes

No

STI/STD/HPV

Yes

No

Hepatitis

Yes

No

If hepatitis, please specify

HIV/AIDS

Yes

No

Tumor, abnormal growth

Yes

No

Radiation therapy

Yes

No

Chemotherapy, immunosuppressive medication

Yes

No

Emotional difficulties

Yes

No

Psychiatric treatment or antidepressant medication

Yes

No

Concentration problems or ADD/ADHD

Yes

No

Alcohol/recreational drug use

Yes

No

ARE YOU:

Presently being treated for any other illness

Yes

No

Aware of a change in your health in the last 24 hours (e.g., fever, chills, new cough, or diarrhea)

Yes

No

Taking medication for weight management

Yes

No

Taking dietary supplements, vitamins, and/or probiotics

Yes

No

Often exhausted or fatigued

Yes

No

Experiencing frequent headaches or chronic pain

Yes

No

A smoker, smoked previously or other (e.g. smokeless tobacco, vaping, e-cigarettes, and cannabis)

Yes

No

Considered a touchy/sensitive person

Yes

No

Often unhappy or depressed

Yes

No

Taking birth control pills

Yes

No

Currently pregnant

Yes

No

Diagnosed with a prostate disorder

Yes

No

Describe any current medical treatment, impending surgery, genetic/development delay, or other treatment that may possibly affect your dental treatment. (i.e. Botox, Collagen Injections)

List all medications, supplements, vitamins, and/or probiotics taken within the last two years.

Drug

Purpose

Drug

Purpose

Drug

Purpose

Drug

Purpose

Drug

Purpose

Drug

Purpose

PLEASE ADVISE US IN THE FUTURE OF ANY CHANGE IN YOUR MEDICAL HISTORY OR ANY MEDICATIONS YOU MAY BE TAKING.

Patient's Signature

Date

Submit

Medical History Form

Do you have or have you ever had:

ARE YOU:

List all medications, supplements, vitamins, and/or probiotics taken within the last two years.

PLEASE ADVISE US IN THE FUTURE OF ANY CHANGE IN YOUR MEDICAL HISTORY OR ANY MEDICATIONS YOU MAY BE TAKING.

Thank You!