New Patient Form PATIENT FORMS MEDICAL HISTORY Patient Name Nickname Age Name of Physician/and their specialty Most recent physical examination Purpose What is your estimate of your general health? Excellent Good Fair Poor DO YOU HAVE OR HAVE YOU EVER HAD: 1. hospitalization for illness or injury 1 YES NO 2. An allergic reaction to Aspirin, ibuprofen, acetaminophen, codeine Penicillin Erythromycin Tetracycline Sulfa Local anesthetic Fluoride Metals (nickel, gold, silver) Latex Other 2. Other allergic reaction(s) 3. Heart problems, or cardiac stent within the last six months 3 YES NO 4. History of infective endocarditis 4 YES NO 5. Artificial heart valve, repaired heart defect (PFO) 5 YES NO 6. Pacemaker or implantable defibrillator 6 YES NO 7. Orthopedic implant (joint replacement) 7 YES NO 8. Rheumatic or scarlet fever 8 YES NO 9. High or low blood pressure 9 YES NO 10. A stroke (taking blood thinners) 10 YES NO 11. Anemia or other blood disorder 11 YES NO 12. Emphysema, shortness of breath, sarcoidosis 12 YES NO 13. Tuberculosis, measles, chicken pox 13 YES NO 14. Asthma 14 YES NO 15. Breathing or sleep problems (i.e.sleep apnea, snoring, sinus) 15 YES NO 16. Kidney disease 16 YES NO 17. Liver disease 17 YES NO 18. Jaundice 18 YES NO 19. Hormone deficiency 19 YES NO 20. Diabetes (HbA1c= ) 20 YES NO 21. Stomach or duodenal ulcer 21 YES NO 22. Digestive disorders (i.e.celiac disease, gastric reflux) 22 YES NO 23. Osteoporosis/osteopenia (i.e.taking bisphosphonates) 23 YES NO 24. Arthritis 24 YES NO 25. Autoimmune disease (i.e. rheumatoid arthritis, lupus, scleroderma) 25 YES NO 26. Glaucoma 26 YES NO 27. Contact lenses 27 YES NO 28. Head or neck injuries 28 YES NO 29. Neurologic disorders (ADD/ADHD, prion disease) 29 YES NO 30. Viral infections and cold sores 30 YES NO 31. STI/STD/GPV 31 YES NO 32.Hepatitis (type 32 YES NO 33. HIV/AIDS 33 YES NO 34. Tumor, abnormal growth 34 YES NO 35. Radiation therapy 35 YES NO 36. Medication 36 YES NO 37. Emotional difficulties 37 YES NO 38. Psychiatric treatment 38 YES NO 39. Antidepressant medication 39 YES NO 40. Alcohol / recreational drug use 40 YES NO 41.Presently being treated for any other illness 41 YES NO 42. Aware of a change in your health in the last 24 hours (i.e. fever, chills, new cough, or diarrhea) 42 YES NO 43. Taking medication for weight management 43 YES NO 44. Taking dietary supplements 44 YES NO 45. Often exhausted or fatigued 45 YES NO 46. Experiencing frequent headaches 46 YES NO 47. A smoker, smoked previously or use smokeless tobacco 47 YES NO 48. Considered a touchy / sensitive person 48 YES NO 49. Often unhappy or depressed 49 YES NO 50. FEMALE - taking birth control pills 50 YES NO 51. FEMALE - pregnant 51 YES NO 52. MALE - prostate disorders 52 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, and or vitamins taken within the last two years. Drug Purpose Drug Purpose PLEASE ADVISE US IN THE FUTURE OF ANY CHANGE IN YOUR MEDICAL HISTORY OR ANY MEDICATIONS YOU MAY BE TAKING.
