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COVID 19 Safety Protocols
(616) 531-0360
COVID 19 Safety Protocols
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COVID-19 Safety Protocols
Appointments
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Pay Online
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Safety & Visits
COVID-19 Safety Protocols
Contact
Request an Appointment
(616) 531-0360
Home
About
Meet the Dentists
Meet the Staff
Before & After Gallery
Patient Testimonials
Services
Preventive Dentistry
Periodontal Deep Cleanings
Gum Disease Treatments
Fluoride Treatments
Oral Examinations
Dental Sealants
Oral Cancer Screening
Cosmetic Dentistry
Invisalign®
Cosmetic Bonding
Composite Fillings
Porcelain Veneers
Dental Crowns
Teeth Whitening
Zoom Teeth Whitening
Restorative Dentistry
Porcelain Bridges
Dentures
Dental Implants
Root Canal Therapy
Tooth Extractions
Inlays & Onlays
Additional Dental Services
Botox®
Dental Technology
Night Guards
Oral Surgery
Sedation Dentistry
Snoring & Sleep Apnea Devices
Sports Dentistry
TMD, MPD, & TMJ Treatment
Dental Emergencies
Children
Resources
Safety & Visits
COVID-19 Safety Protocols
Appointments
Patient Forms
Dental Blog
Financial Policy
Pay Online
Dental Educational Videos
Safety & Visits
COVID-19 Safety Protocols
Contact
Request an Appointment
(616) 531-0360
Adult Medical History Form
Adult Medical History Form
Patient Name
Patient Email
Date of Birth:
Date Format: MM slash DD slash YYYY
Patient Age
Current Physician
Most recent medical physical examination:
Date Format: MM slash DD slash YYYY
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 *
*
Date Format: MM slash DD slash YYYY
Comments
This field is for validation purposes and should be left unchanged.