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Medical History Update
Personal Information
Date:
Name:
Circle One
Dr.
Mr.
Mrs.
Ms.
I prefer to be called
Sex:
F
M
Birthdate:
Age:
SS#:
Medical History
Check any of the following that you have had or have at the present:
Osteoporosis
Bisphosphonate therapy
Tumor or malignancy
Heart disease or heart attack
Asthma
Chemotherapy
High blood pressure
Diabetes
Radiation treatment
Heart murmur/valve conditions
Thyroid issues
Frequent vomiting
Rheumatic fever
Hepatitis A, B, C
Blood transfusion
Heart pacemaker
High Anxiety
Anaphylaxis
Heart surgery
Epilepsy or seizures
Glaucoma
Stroke
Psychiatric treatment
Sickle cell disease/traits
Kidney disease
Artificial joints
Frequent Headaches
Back/neck pain
Acid Reflux/GERD
Hearing impaired
Arthritis
AIDS or HIV+
Fainting
Anemia
Congenital heart lesions
Herpes
Bleeding disorders
COPD/lung disease
Shingles
Hay fever
Chronic Sinus issues
Eating disorders
Ulcers
Liver disease
Autism
Other:
Major surgeries last 2 years (type and year):
Yes
No
Have you been hospitalized during the past two years?
Yes
No
Have you been asked by your medical doctor to premedicate before any dental treatment?
Yes
No
Do you smoke or use chewing tobacco?
If Yes, How many packs per day?
Yes
No
Do you smoke or ingest marijuana?
Yes
No
Do you drink alcohol?
If yes:
Occasionally
Weekly
Daily
For Women Only:
Yes
No
Are you pregnant?
If yes, due date:
Yes
No
Are you taking birth control pills?
Yes
No
Could you be pregnant?
Yes
No
Are you nursing?
Are you allergic or have you reacted adversely to any of the following (check all that apply):
Aspirin
Ibuprofen
Latex, Metals, Plastic
Penicillin
Codeine
Sulfa Drugs
Local Anesthesia
Barbiturates
Nitrous Oxide
Acetaminophen/Tylenol
Erythromycin
Tetracycline
Other:
Please list all medications you are currently taking, including prescription drugs, over-the-counter drugs, vitamins, herbal remedies and supplements. (If you have a list, please present list)