Microsoft word - medical history

Today’s Date: _____________________________________ Patient Name:________________________________________________________________Birthdate:____________________________________ 1. Have you been under the care of a medical doctor during the past 2 years?. Yes If yes, for what?____________________________________________________________________________________________________ Physician’s Name?____________________________________________________City__________________Phone____________________ When was your last medical doctor visit?_________________________________________________________________________________ Have you taken any medication or drugs during the past 2 years? If yes what?. Yes Have you ever taken any of the fol owing drugs? (please circle any you have taken): Fosamax/ Alendronate, Fosamax Plus D, Reclast, Actonel, Aredia, Zometa, Boniva, Skelid, Didronel or any Bisphosphonates Have you ever been treated for cancer?. Yes Have you ever been treated for osteoporosis?. Yes Have you ever had intravenous treatment for cancer or osteoporosis?. Yes Are you taking any medication, drugs or pil s now?. Yes If yes, please list name and dosage_____________________________________________________________________________________ _________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________ Are you aware of having an al ergic (or adverse) reaction to any medication or substance?. Yes If yes, please list:___________________________________________________________________________________________________ Have you been a patient in the hospital during the past 5 years?. Yes If yes, for what?____________________________________________________________________________________________________ Indicate which of the fol owing you have had, or have at present: Circle “yes” or “no” to each item: Heart Surgery……………………………………………………… Yes Asthma……………………………………………………………. Yes If yes, When?___________________________________________________ If yes, When was last attack?______________________________________ Heart Disease……………………………………………………. Yes Emphysema……………………………………………………. Yes Heart Attack………………………………………………………. . Yes Psychiatric/Psychological Care………………………………. If yes, When?___________________________________________________ Neurological Disorders………………………………………… Yes Heart Stint / Shunt………………………. Epilepsy or Seizures…………………………………………. If yes, When?___________________________________________________ Arthritis/Rheumatism…………………………………………. Angina (Chest Pain)…………………………………………………. Yes Tuberculosis Disease…………………………………………. Yes Congenital Heart Disease…………………………………….……. Yes No Nervous/Anxious……………………………………………… Heart Murmur…………………………………………………………. Yes Artificial Joints (hip, knee, etc)………………………………… Yes Mitral Valve Prolapse………………………………………………… Yes No Stomach Ulcers………………………………………………. Yes If yes, When & What placed?______________________________________ Fainting or Dizzy Spel s………………………………………. Yes Artificial Heart Valve………………………………………………… Yes No Cold Sores/Fever Blisters/Mouth Ulcers (Frequent)….……. Yes Heart Pacemaker……………………………………………………… Yes No Thyroid Problems……………………………………………… Rheumatic Heart Disease……………………………………………. Yes No Sexual y Transmitted Disease (STD)………………………. Rheumatic Fever……………………………………………………… Yes Hepatitis A (infectious) B (serum) or C……………………… Congestive Heart Failure……………………………………………. Yes H.I.V. Positive…………………………………………………. High Blood Pressure…………………………………………………. Yes No A.I.D.S…………………………………………………………. Stroke…………………………………………………………………… Yes Sickle Cel Disease……………………………………………. Sinus Trouble…………………………………………………….……… Yes Yel ow Jaundice………………………………………………. Latex Sensitivity…………………………………………………………. Yes No Blood Transfusion……………………………………………. Kidney Problems………………………………………………………… Yes No Hemophilia……………………………………………………. Anemia ………………………………………………………… Bruise Easily ……………….……………………………………………. Yes No Liver Disease…………………………………………………… Yes If yes, Do you take aspirin daily? ____________________________________ Radiation Therapy………………………………………………. Yes Al ergies or Hives…………………………….……………………….… Yes No Chemotherapy…………………………………………………… Yes Swol en Ankles…………………………………………………….…… Yes No Tumors……………………………………………………………. Yes Diabetes……………….…………………………………………………. Yes No Alcohol Intolerant……………………….…………….………. Yes If yes, What Type?________________________________________________ Glaucoma…………………….………………………………… Yes Do you use more than 2 pil ows to sleep?. Yes Do you have or have you had any disease, condition, or problem not listed?. Yes If yes, please list____________________________________________________________________________________________________ If yes, How many times per week?_______________________________________________________________________________________ Are you aware of clenching or grinding your teeth?. Yes Do you experience frequent bad breath?. Yes Are you satisfied with the appearance of your teeth?. Yes WOMEN: Are you: Pregnant? ___Yes No , ____ Months Nursing? Yes No Taking birth control pills or injections? Have you had any implants or augmentations done?.Yes No When was that done?___________________________________ I understand the above information is necessary to provide me with dental care in a safe and efficient manner. I have answered all questions to the best of my knowledge. Should further information be needed, you have my permission to ask the respective health care provider or agency, who may release such information to you. I will notify the doctor of any change in my health or medication. ______________________________________________________________________________________________ ____________________________________________________ PATIENT OR LEGAL GUARDIAN SIGNATURE INDICATE HEALTH / MEDICATION CHANGES OR NO CHANGES ___________________________________________________________ __________________________________________ ___________________________________________________________ __________________________________________ ___________________________________________________________ __________________________________________ ___________________________________________________________ __________________________________________ ___________________________________________________________ __________________________________________ ___________________________________________________________ __________________________________________ ___________________________________________________________ __________________________________________ ___________________________________________________________ __________________________________________ ___________________________________________________________ __________________________________________ ___________________________________________________________ __________________________________________ ___________________________________________________________ __________________________________________ ___________________________________________________________ __________________________________________ ___________________________________________________________ __________________________________________ ___________________________________________________________ __________________________________________ ___________________________________________________________ __________________________________________ ___________________________________________________________ __________________________________________ ___________________________________________________________ __________________________________________ ___________________________________________________________ __________________________________________ ___________________________________________________________ __________________________________________ ___________________________________________________________ __________________________________________ ___________________________________________________________ __________________________________________ ___________________________________________________________ __________________________________________ ___________________________________________________________ __________________________________________ ___________________________________________________________ __________________________________________ ___________________________________________________________ __________________________________________ ___________________________________________________________ __________________________________________ ___________________________________________________________ __________________________________________ ___________________________________________________________ __________________________________________ ___________________________________________________________ __________________________________________

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