Medical History Form

If you have any questions, please call our office at 204-837-4517.

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?

PLEASE ANSWER YES OR NO TO THE FOLLOWING:

1. hospitalization for illness or injury

26. osteoporosis/osteopenia (i.e. taking bisphosphonates)

2. an allergic reaction to

27. arthritis

)

28. glaucoma

29. contact lenses

30. head or neck injuries

31. epilepsy, convulsions (seizures

32. neurologic problems (attention deficit disorder)

3. heart problems, or cardiac stent within the last six months

33. viral infections and cold sores

4. history of infective endocarditis

34. any lumps or swelling in the mouth

5. artificial heart valve, repaired heart defect (PFO)

35. hives, skin rash, hay fever

6. pacemaker or implantable defibrillator

36. venereal disease

7. artificial prosthesis (heart valve or joints)

37. hepatitis (type

8. rheumatic or scarlet fever

38. HIV / AIDS

9. high or low blood pressure_

39. tumor, abnormal growth

10. a stroke (taking blood thinners)

40. radiation therapy

11. anemia or other blood disorder

41. chemotherapy

12. prolonged bleeding due to a slight cut (INR > 3.5)

42. emotional problems

13. emphysema, sarcoidosis

43. psychiatric treatment

14. tuberculosis

44. antidepressant medication

15. asthma

45. alcohol / drug dependency

16. breathing or sleep problems (i.e. snoring, sinus)

WHAT IS YOUR IMMEDIATE CONCERN? 

17. kidney disease

46. presently being treated for any other illness

18. liver disease

47. aware of a change in your general health

19. jaundice

48. taking medication for weight management (i.e. fen-phen)

20. thyroid, parathyroid disease, or calcium deficiency

49. taking dietary supplements

21. hormone deficiency

50. often exhausted or fatigued

22. high cholesterol or taking statin drugs

51. subject to frequent headaches

23. diabetes (HbA1c = 

)

52. a smoker or smoked previously

24. stomach or duodenal ulcer

53. considered a touchy person

54. often unhappy or depressed

25. digestive disorders (i.e. gastric reflux)

55. FEMALE - taking birth control pills

56. FEMALE - pregnant

57. MALE - prostate disorders

Describe any current medical treatment, impending surgery, or other treatment that may possibly affect your dental treatment.

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

Drug

Purpose

Drug

Purpose

Ask for an additional sheet if you are taking more than 6 medications

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

DATE:

DATE:

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