Patient's Name

Height

Weight

Gender

Date of Birth
Please describe your current health:

Please describe the symptoms you are currently having today:

Have there been any changes in your general health in the past year?

If yes, please describe:

Are you now under a doctor’s care for a particular problem at this time?

If yes, why?

Date of last physical exam

Have you ever been hospitalized or had a serious illness?

If yes, why?

Have you ever had surgery?

If yes, when and what for?
Date of surgery: Reason for surgery:
Date of surgery: Reason for surgery:


Indicate which of the following you have had or have at present. Circle ”yes” or ”no” to each item

Congenital heart disease, cardiovascular disease
Lung disease
Implants placed anywhere in the body
Bleeding disorder, anemia, bleeding tendency, blood transfusion? Do you bruise easily?

None of the Above

Kidney disease or kidney failure, requiring dialysis?
Liver disease (jaundice, hepatitis A, B, or C)
Thyroid disease
Arthritis

None of the Above

Stomach ulcers or colitis
Significant weight loss or gain
Clicking, popping, or pain within the jaw joint and/or difficulty opening mouth?
Seizures, convulsions, epilepsy, fainting or dizziness? Y

None of the Above

Frequent or recurring mouth sores
Sinus or nasal problems
Glaucoma
Sleep apnea

None of the Above

Diabetes
Osteoporosis or osteopenia

None of the Above

Any cancer, radiation, or chemotherapy?

Describe:

Date of your last treatment?

Do you have any other disease, condition or problem not listed above that you think the doctor should know about?

If yes, please explain:


Family Medical History
Do you have a family history of any of the following? If yes, indicate the relationship.

Diabetes?

Relationship

Heart disease?

Relationship

Tumors?

Relationship

Sleep Apnea?

Relationship

None of the Above

Cancer?

Relationship

Bleeding problems?

Relationship

Lung disease?

Relationship

None of the Above


Female Patients

Are you pregnant, or is there any chance you might be pregnant?

Relationship


Medications
Are you using any of the following:

Antibiotics?
Anticoagulants (blood thinners)?
Heart medications?
Steroids (cortisone, prednisone, etc.)?

None of the Above

Antianxiety agents, antidepressants or other psychiatric medications?
Prescription pain medication?
Aspirin or drugs such as Motrin, Aleve, Ibuprofen?
Insulin or oral anti-diabetic drugs?

None of the Above

Blood pressure medications?
Bisphosphonates, medications to strengthen your bones, IV medications, or any other cancer drugs?

If yes, list drugs used and time of use.

None of the Above

Please list any specific medications indicated above and/or any other medications not listed above that you are currently taking including prescription medications, diet drugs, over the counter medications, herbal or holistic remedies, vitamins or minerals:

Medication

Dosage

Medication

Dosage

Medication

Dosage

Medication

Dosage

Medication

Dosage

Medication

Dosage

Medication

Dosage

Medication

Dosage


Allergies
Are you allergic to or have you had an adverse reaction to:

Latex?
Food products?
Sedatives, barbiturates?

None of the Above

Codeine or other pain killers?
Aspirin, Motrin, Aleve, or ibuprofen?
Penicillin or other antibiotics?

None of the Above

Have you or an immediate family member had any problem associated with local anesthesia, general anesthesia, and/or intravenous sedation?

If yes, which anesthetic?

Relationship?

Other drug or food allergies not listed above:


Social History

Have you ever smoked, vaped or chewed tobacco?

If yes, for how long?

Have you ever sought professional care or been hospitalized for:

Substance abuse?
Emotional disorders?
Alcoholism?

None of the Above

Do you use:

Alcohol?

How often?

Marijuana?

How often?

Recreational drugs?

How often?

None of the Above


Dental History

Have you had any adverse effects from dental treatment?

If Yes, please explain?

Do you wish to talk to the doctor privately about anything?