Adult Medical History | Grandville MI | Grandville Dental Health Center

Adult Medical History Form

Patient Name

Patient Email

Date of Birth:

Patient Age

Current Physician

Most recent medical physical examination:

Purpose:

What is your estimate of your general health?

Excellent
Good
Fair
Poor

DO YOU HAVE OR HAVE YOU EVER HAD:

Hospitalization for illness or injury:

Yes
No

An allergic reaction to aspirin, ibuprofen, acetaminophen, codeine:

Yes
No

An allergic reaction to penicillin:

Yes
No

An allergic reaction to erythromycin:

Yes
No

An allergic reaction to tetracycline:

Yes
No

An allergic reaction to sulpha:

Yes
No

An allergic reaction to local anesthetic:

Yes
No

An allergic reaction to fluoride:

Yes
No

An allergic reaction to metals (nickel, gold, silver):

Yes
No

An allergic reaction to latex:

Yes
No

An allergic reaction to other:

Heart problems or cardiac stent in last six months:

Yes
No

History of infective endocarditis:

Yes
No

Artificial heart valve or repaired heart defect (PFO):

Yes
No

Pacemaker or implantable defibrillator:

Yes
No

Artificial prosthesis (heart valve or joints):

Yes
No

Rheumatic or scarlet fever:

Yes
No

High or low blood pressure:

Yes
No

A stroke (taking blood thinners):

Yes
No

Anemia or other blood disorder:

Yes
No

Prolonged bleeding due to a slight cut (INR>3.5):

Yes
No

Emphysema or sarcoidosis:

Yes
No

Tuberculosis:

Yes
No

Asthma:

Yes
No

Breathing or sleeping problems (snoring or sinus):

Yes
No

Kidney disease:

Yes
No

Liver disease:

Yes
No

Jaundice:

Yes
No

Thyroid, parathyroid disease or calcium deficiency:

Yes
No

Hormone deficiency:

Yes
No

High cholesterol or taking statin drugs:

Yes
No

Diabetes (HbA1c):

Yes
No

Stomach or duodenal ulcer:

Yes
No

Digestive disorders (gastric reflux):

Yes
No

Osteoporosis/osteopenia (taking bisphosphonates):

Yes
No

Arthritis:

Yes
No

Glaucoma:

Yes
No

Contact lenses:

Yes
No

Head or neck injuries:

Yes
No

Epilepsy or convulsions (seizures):

Yes
No

Neurologic problems (ADD):

Yes
No

Viral infections and cold sores:

Yes
No

Any lumps or swelling in the mouth:

Yes
No

Hives, skin rash or hay fever:

Yes
No

Hepatitis:

Yes
No

Type:

Venereal disease:

Yes
No

HIV/AIDS:

Yes
No

Tumor or abnormal growth:

Yes
No

Radiation therapy:

Yes
No

Chemotherapy:

Yes
No

Emotional problems:

Yes
No

Psychiatric treatment:

Yes
No

Antidepressant medication:

Yes
No

Alcohol/drug dependency:

Yes
No

ARE YOU:

Presently being treated for any other illness:

Yes
No

Aware of a change in your general health:

Yes
No

Taking medication for weight management:

Yes
No

Taking dietary supplements:

Yes
No

Often exhausted or fatigued:

Yes
No

Subject to frequent headaches:

Yes
No

A smoker or smoked previously:

Yes
No

Often unhappy or depressed:

Yes
No

FEMALE - taking birth control pills:

Yes
No

FEMALE - pregnant:

Yes
No

MALE - prostate disorders:

Yes
No

MEDICATION TREATMENT HISTORY

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 last two years.

PLEASE ADVISE US OF ANY CHANGE IN YOUR MEDICATIONS OR MEDICAL HISTORY

PATIENT SIGNATURE **

DATE **

Comments

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