Medical History FormIf you have any questions, please call our office at (204) 837-4517. Patient's Name * First Name Last Name Nickname * Age * Name of Physician/and their specialty * Most recent physical examination * Purpose of most recent physical examination * What is your estimate of your general health? * Excellent Good Fair Poor DO YOU HAVE OR HAVE EVER HAD: 1. Hospitalization for illness or injury * Yes No 2. An allergic reaction to: * aspirin, ibuprofen, acetaminophen, codeine penicillin erthromycin tetracycline sulpha local anesthetic fluoride metals (nickel, gold, silver) latex other If you selected other please specify 3. Heart problems, or cardiac stent within the last six months * Yes No 4. History of infective endocarditis * Yes No 5. Artificial heart valve, repaired heart defect (PFO) * Yes No 6. Pacemaker or implantable defibrillator * Yes No 7. Artificial prosthesis (heart valve or joints) * Yes No 8. Rheumatic or scarlett fever * Yes No 9. High or low blood pressure * Yes No 10. A stroke (or taking blood thinners) * Yes No 11. Anemia or other blood disorder * Yes No 12. Prolonged bleeding due to a slight cut (INR>3.5) * Yes No 13. Emphysema, sarcoidosis * Yes No 14. Tuberculosis * Yes No 15. Asthma * Yes No 16. Breathing or sleeping problems (ie. snoring, sinus) * Yes No 17. Kidney disease * Yes No 18. Liver disease * Yes No 19. Jaundice * Yes No 20. Thyroid, parathyroid disease, or calcium deficiency * Yes No 21. Hormone deficiency * Yes No 22. High cholesterol or taking statin drugs * Yes No 23. Diabetes * Yes No HbA1c = 24. Stomach or duodenal ulcer * Yes No 25. Digestive disorders (i.e. gastric reflux) * Yes No 26. osteoporosis/osteopenia (ie. taking bisphosphonates) * Yes No 27. Arthrities * Yes No 28. Glaucoma * Yes No 29. Contact lenses * Yes No 30. Head or neck injuries * Yes No 31. Epilepsy, convulsions (seizures) * Yes No 32. Neurological problems (attention deficit disorder) * Yes No 33. Viral infections and cold sores * Yes No 34. Any lumps or swelling in the mouth * Yes No 35. Hives, skin rash, hay fever * Yes No 36. Venereal disease * Yes No 37. Hepatitis * Yes No Hepatitis type: 38. HIV/AIDS * Yes No 39. Tumor, abnormal growth * Yes No 40. Radiation therapy * Yes No 41. Chemotherapy * Yes No 42. Emotional problems * Yes No 43. Psychiatric treatment * Yes No 44. Antidepressant medication * Yes No 45. Alcohol / drug dependency * Yes No ARE YOU: 46. Presently being treated for any other illness? * Yes No 47. Aware of a change in your general health? * Yes No 48. Taking medication for weight management (i.e. fen-phen)? * Yes No 49. Taking dietary supplements? * Yes No 50. Often exhausted or fatigued? * Yes No 51. Subject to frequent headaches? * Yes No 52. A smoker or smoked previously? Yes No 53. Considered a touchy person? * Yes No 54. Often unhappy or depressed? * Yes No 55. FEMALE - Taking birth control pills? * Yes No n/a 56. FEMALE - Pregnant? * Yes No n/a 57. MALE - Prostate Disorders * Yes No n/a 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 the last two years: * Drug & purpose for each. PLEASE ADVISE US IN THE FUTURE OF ANY CHANGES IN YOUR MEDICAL HISTORY OR ANY MEDICATIONS YOU MAY BE TAKING Patient's Signature * Date * Thank you!
