Medical History

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    Patient Name *

    Date Of Birth *

    PATIENT INFORMATION

    R (leave Blank if you do not understand question)
    ( * ) Marks field are mandatory to fill out

    Is your general health good? *
    YesNo
    Has there been a change in your health within the last year? *
    YesNo
    Have you been hospitalized or had a serious illness in the last three years? *
    YesNo
    If YES, why? *
    Are you being treated by a physician now? *
    YesNo
    For what? *
    Date of last medical exam? *
    Date of last Dental exam *
    Have you had problems with prior dental treatment? *
    YesNo
    Are you in pain now? *
    YesNo

    HAVE YOU EXPERIENCED

    ( * ) Marks field are mandatory to fill out

    Chest pain (angina)? *
    YesNo
    Swollen ankles? *
    YesNo
    Shortness of breath? *
    YesNo
    Recent weight loss, fever, night sweats? *
    YesNo
    Persistent cough, coughing up blood? *
    YesNo
    Bleeding problems, bruising easily? *
    YesNo
    Sinus problems? *
    YesNo
    Difficulty swallowing? *
    YesNo
    Diarrhea, constipation, blood in stools? *
    YesNo
    Frequent vomiting, nausea? *
    YesNo
    Difficulty urinating, blood in urine? *
    YesNo
    Dizziness? *
    YesNo
    Ringing in ears? *
    YesNo
    Headaches? *
    YesNo
    Fainting spells? *
    YesNo
    Blurred vision? *
    YesNo
    Seizures? *
    YesNo
    Excessive thirst? *
    YesNo
    Frequent urination? *
    YesNo
    Dry mouth? *
    YesNo
    Jaundice? *
    YesNo
    Joint pain, stiffness? *
    YesNo

     

    DO YOU HAVE OR HAVE YOU HAD

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    Heart disease? *
    YesNo
    Heart attack, heart defects? *
    YesNo
    Heart murmurs? *
    YesNo
    Rheumatic fever? *
    YesNo
    Stroke, hardening of arteries? *
    YesNo
    High blood pressure? *
    YesNo
    Asthma, TB, emphysema, other lung diseases? *
    YesNo
    Hepatitis, other liver disease? *
    YesNo
    Stomach problems, ulcers? *
    YesNo
    Allergies to: drugs, foods, medications, latex? *
    YesNo
    Family history of diabetes, heart problems, tumors? *
    YesNo
    HIV+/AIDS *
    YesNo
    Tumors, cancer? *
    YesNo
    Arthritis, rheumatism? *
    YesNo
    Eye diseases? *
    YesNo
    Skin diseases? *
    YesNo
    Anemia? *
    YesNo
    VD (syphilis or gonorrhea)? *
    YesNo
    Herpes? *
    YesNo
    Kidney, bladder disease? *
    YesNo
    Thyroid, adrenal disease? *
    YesNo
    Diabetes? *
    YesNo

     

    DO YOU HAVE OR HAVE YOU HAD

    ( * ) Marks field are mandatory to fill out

    Psychiatric care? *
    YesNo
    Radiation treatments? *
    YesNo
    Chemotherapy? *
    YesNo
    Prosthetic heart valve? *
    YesNo
    Artificial joint? *
    YesNo
    Hospitalization? *
    YesNo
    Blood transfusions? *
    YesNo
    Surgeries? *
    YesNo
    Pacemaker? *
    YesNo
    Contact lenses? *
    YesNo

     

    ARE YOU TAKING

    ( * ) Marks field are mandatory to fill out

    Recreational drugs? *
    YesNo
    Drugs, medications, over-the-counter medicines
    (including Aspirin), natural remedies? *
    YesNo
    Tobacco in any form? *
    YesNo
    Alcohol? *
    YesNo

     

    WOMEN ONLY

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    Are you or could you be pregnant or nursing? *
    YesNo
    Taking birth control pills? *
    YesNo

     

    ALL PATIENTS

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    Do you have or have you had any other diseases or medical problems NOT listed on this form? If so, please explain *


    To the best of my knowledge, I have answered every question completely and accurately. I will inform my dentist of any change in my health and/or medication.

    Patient Name *

    Date *