Medical history questionare – update

MEDICAL HISTORY QUESTIONARE – UPDATE
Name _________________________________________ Address: _______________________________________ City, State, Zip: _____________________________________ Home Phone ________________ Cell Phone _________________ Work Phone _________________ What is your estimate of your current health? Poor ____________ Fair ____________ Good ____________
HAVE YOU EVER HAD THE FOLLOWING: YES
Hospitalization for illness or injury …. Arthritis………………………… • Aspirin, Ibuprofen…………….  • Penicillin…………………….….  • Sulfa………………………….…  • Codeine……………………….…  • Sedative…………………………  • Local Anesthetics……………….  • Latex……………………………  • Metals………………………….  • Any other allergies…………….  Heart problems…………………….…… Heart murmur……………………….…. Rheumatic fever………………………. Pacemaker…………………….………….  Stroke…………………….………………  Taken steroids within the last 2 years.  Artificial joint or heart valve……………. Ever taken Bisphosphonates (IV or Oral  (Actonel, Bonica, Fosamax, Skelid, Didronel, Aredia, Zometa, Bonefos) Anemia or other blood disorders………. Prolonged bleeding due to slight cut…….  Taking steroids…………………… Tuberculosis………………………….…. Presently being treated for illness…  Asthma/Emphysema………………….….  Aware of a change in your health…  Sinus problems…………………………. Often exhausted or fatigues…………  Kidney disease…………………………. Subject to frequent headaches………  Jaundice or Liver disease…………….….  A smoker – How many per day…….  Thyroid or parathyroid disease…………. Are you anxious about dentistry…….  Hormone deficiency………………….…. Easily upset…………………….….  High cholesterol………………………….  FEMALE – use birth control pills.…  Diabetes……………………………….… FEMALE – pregnant…………….…  Glaucoma………………………………. MALE – have prostate disorder……  Please describe any current medical treatment, impending or recent surgery, or other treatment that may possibly affect your dental treatment. ____________________________________________________________________________________ __________________________________________________________________________________________________ List (or attach a separate list if extensive) any medications taken within the last two years. __________________________________________________________________________________________________ __________________________________________________________________________________________________ PLEASE ADVISE US IN THE FUTURE OF ANY CHANGE IN YOUR MEDICAL
HISTORY OR ANY MEDICATIONS YOU MAY BE TAKING.
SIGNATURE ___________________________________________________________ DATE _____________
SIGNATURE ___________________________________________________________ DATE _____________
SIGNATURE ___________________________________________________________ DATE _____________

Source: http://www.nwprosthodontics.com/Documents/Medical%20History%20Questionnaire.pdf