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.

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Grandville Dental
Health Center, PC

4050 Del Mar Drive
Grandville, MI 49418

(616) 531-0360

Adult Medical History Form

Adult Medical History Form

DO YOU HAVE OR HAVE YOU EVER HAD:

ARE YOU:

MEDICATION TREATMENT HISTORY