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Contact
Request an Appointment
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 Dentistry
Botox
Dental Technology
Night Guards
Oral Surgery
Sedation Dentistry
Snoring & Sleep Apnea Devices
Sports Dentistry
TMD, MPD, & TMJ Treatment
Dental Emergencies
Children
Resources
Appointments
Patient Forms
Dental Blog
Financial Policy
Pay Online
Dental Educational Videos
Contact
Request an Appointment
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
CAPTCHA
Email
This field is for validation purposes and should be left unchanged.
