Medical History

Medical History

Patient Name

Nickname

Age

Name of Physician/and their specialty

Most Recent Examination

Purpose

What is your estimate of your general health?

Do You Have or Have You Ever Had:

1. hospitalization for illness or injury
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31. head or neck injuries
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2. an allergic reaction to
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6. pacemaker or implantable defibrillator
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3. heart problems, or cardiac stent within the last six months
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33. neurologic disorders (ADD/ADHD, prion disease)
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4. history of infective endocarditis
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34. viral infections and cold sores
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5. artificial heart valve, repaired heart defect (PFO)
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35. any lumps or swelling in the mouth
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6. pacemaker or implantable defibrillator

36. hives, skin rash, hay fever

7. orthopedic implant (joint replacement)
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37. STI / STD / HPV
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8. rheumatic or scarlet fever
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38. hepatitis
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9. high or low blood pressure
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39. HIV / AIDS
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10. a stroke (taking blood thinners)
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40. tumor, abnormal growth
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11. anemia or other blood disorder
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41. radiation therapy
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12. prolonged bleeding due to a slight cut (INR > 3.5)
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42. chemotherapy, immunosuppressive medication
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13. emphysema, shortness of breath, sarcoidosis
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43. emotional difficulties
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14. tuberculosis, measles, chicken pox
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44. psychiatric treatment
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15. asthma
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45. antidepressant medication
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16. breathing or sleep problems (i.e. sleep apnea, snoring, sinus)
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46. alcohol / recreational drug use
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17. kidney disease
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Are You:

18. liver disease
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47. presently being treated for any other illness
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19. jaundice
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48. aware of a change in your health in the last 24 hours (i.e. fever, chills, new cough, or diarrhea)
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20. thyroid, parathyroid disease, or calcium deficiency
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49. taking medication for weight management
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21. hormone deficiency
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50. taking dietary supplements
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22. high cholesterol or taking statin drugs
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51. often exhausted or fatigued
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23. diabetes
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52. experiencing frequent headaches
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24. stomach or duodenal ulcer
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53. a smoker, smoked previously or use smokeless tobacco
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25. digestive disorders (i.e. celiac disease, gastric reflux)
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54. considered a touchy / sensitive person
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26. osteoporosis/osteopenia (i.e. taking bisphosphonates)
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55. often unhappy or depressed
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27. arthritis
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56. taking birth control pills
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28. autoimmune disease
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57. currently pregnant
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29. glaucoma
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58. prostate disorders
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30. contact lenses
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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.
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Drug and Purpose

Drug and Purpose

Drug and Purpose

Drug and Purpose

Drug and Purpose

Drug and Purpose

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