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Microsoft word - medical history (new).doc

MEDICAL HISTORY (ALL RESPONSES ARE KEPT CONFIDENTIAL)
_____________________ ______________ _______________ _______________ ________ _______
Patient’s Name

General Dentist Referring Doctor Medical Doctor
Height Weight

Answer all questions by circling YES (Y) or No (N)

 Heart murmur…………………………. Y N 1. Have you ever had any adverse effects from dental  Heart attack: if yes, when___________ Y N  Heart surgery: if yes, when__________ Y N 2. Do you wear a denture or removable appliance? Y N  High blood pressure…………………… Y N 3. Clicking or Popping of the Jaw Joint, Pain  Low blood pressure…………………… Y N Near Ear, Difficulty Opening Mouth, Grind  Pacemaker……………………………. Y N  Stroke…………………………………. Y N 4. Have you or a family member had problems with general anesthesia?……………………………….Y N  Asthma…………………………………Y N 5. Do you snore or have you been diagnosed with sleep  Emphysema…………………………….Y N apnea?…………………………………………….Y N  Bronchitis………………………………Y N  Tuberculosis……………………………Y N 7. Do you use Marijuana or other “street drugs”?. Y N  Shortness of breath……………………. Y N  Pneumonia…………………………….Y N 9. Are you pregnant or nursing?…………………….Y N If yes, how many months _______________________  Anemia…………………………………Y N 10. Do you wear contact lenses?……………………Y N  Bleed or bruise easily…………………. Y N 11. Are you wearing any oral piercings?……………Y N  Epilepsy/Seizures……………………. Y N Are you taking any of the following medications:
 Fainting ……………………………… Y N  If yes, please indicate name of medication(s).
Psychiatric treatment………………… Y N 7. Liver Disease (Jaundice, Hepatitis) . Y N 3. Anticoagulants (Blood Thinners) . Y N 8. Digitalis, Inderal, Nitroglycerin,Calcium Channel Blockers, Procardia, or other Heart Medicine? . Y N If so, how much daily ____________________ Surgery………………………………. Y N 10. Antihistamines or Decongestants . Y N Radiation……………………………. Y N 11. PLEASE LIST ALL MEDICATIONS YOU ARE
Chemotherapy………………………. Y N TAKING ON THE BACK SIDE OF THIS FORM.
Oral cancer drugs……………………. Y N 16. Immune System ……………………………. Y N Are you allergic or had a bad reaction to:
HIV/AIDS……………………………. Y N 17. Have you had an organ or tissue transplant…Y N answering yes, please circle condition(s).
18. Frequent or Recurring Mouth Sores . .Y N 1. Local Anesthetic (Novocaine, etc.)……………. Y N 19. Implants placed anywhere in your body 2. Penicillin, Amoxicillin, Cephalosporins 4. Aspirin or Ibuprofen . Y N 5. Codeine or other Pain Killers . Y N  Do you have any other disease or condition not listed above that the doctor should know about?………Y N If yes, please list _____________________________ 8. Soybeans………………………………………. Y N  Do you wish to talk to the doctor privately about 9. Sulfa …………………………………………….Y N 9. Other Allergies or Reactions________________Y N
Do you have or have you ever had:
For Women Only:
If answering yes,
 Antibiotics and other medications may interfere with please circle condition(s) that pertains to you.
the effectiveness of oral contraceptives. Please advise the doctor if there is any chance of your being pregnant. 2. Congenital heart disease ……………… Y N 3. Cardiovascular Disease/Heart Condition……Y N  Angina………………………………. Y N
I understand the importance of a truthful Health History to assist the doctor in providing the best care possible.
________________
____________________________________________
DRS. DELGADO & KUZMIK, P.C.

Edward B. Delgado, D.D.S.
Diplomates of the American Board of Oral and Michael D. Kuzmik, D.D.S.
_________________________________________________________________________________________

MEDICATION STRENGTH
__________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________

Source: http://www.dkoms.com/wp-content/uploads/2013/02/medical-history.pdf

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