You can still download the fillable PDF here, and print to bring with you to your appointment. Patient Name* First Last Email* NicknameAge*Name of Physician/and their specialtyMost recent physical examinationPurposeWhat is the 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 or bad reaction to any of the following: aspirin, ibuprofen, acetaminophen, codeine penicillin erythromycin tetracydine sulfa local anesthetic flouride chlorhexidine (CHX) latex metals (nickel, gold, silver) nuts fruit other List what metals you are allergic to:*List what nuts you are allergic to:*List what fruits you are allergic to:*List 'other' allergies:*heart problems or cardiac stent within the last six months* Yes No history of infective endocarditis* Yes No artificial heart valve, repaired heart defect (PFO)* Yes No pacemaker or implantable defibrillator* Yes No orthopedic implant (joint replacement)* 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 pneumonia, emphysema, shortness of breath, sarcoidosis* Yes No chronic ear infections, tuberculosis, measles, chicken pox* Yes No asthma* Yes No breathing or sleep problems (i.e. sleep apnea, snoring, 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* Yes No HbA1c =*stomach or duodenal ulcer* Yes No digestive or eating disorders (e.g., celiac disease, gastric reflux, bulimia, anorexia)* Yes No osteoporosis/osteopenia (i.e. taking bisphosphonates)* Yes No arthritis* Yes No autoimmune disease (i.e. rheumatoid arthritis, lupus, scleroderma)* Yes No glaucoma* Yes No contact lenses* Yes No head or neck injuries* Yes No epilepsy, convulsions (seizures)* Yes No neurologic disorders (ADD/ADHD, prion disease)* Yes No viral infections and cold sores* Yes No any lumps or swelling in the mouth* Yes No hives, skin rash, hay fever* Yes No STI/STD/HPV* Yes No hepatitis* Yes No hepatitis type:*HIV/AIDS* Yes No tumor, abnormal growth* Yes No radiation therapy* Yes No chemotherapy, immunosuppressive medication* Yes No emotional difficulties* Yes No antidepressant medication* Yes No alcohol/recreational drug use* Yes No ARE YOU:presently being treated for any other illness* Yes No aware of a change in your health in the last 24 hours (i.e. fever, chills, new cough, or diarrhea)* Yes No taking dietary supplements* Yes No often exhausted or fatigued* Yes No experiencing frequent headaches* Yes No a smoker, smoked previously or use smokeless tobacco* Yes No considered a touchy/sensitive person* Yes No often unhappy or depressed* Yes No taking birth control pills* Yes No currently pregnant* Yes No diagnosed with a prostate disorder* Yes No Describe any current medical treatment, impending surgery, genetic/development delay, or other treatment that may possibly affect your dental treatment. (i.e. Botox, Collagen Injections)List all medications, supplements, and or vitamins taken within the last two years. Drug Purpose Drug Purpose Drug Purpose Drug Purpose Drug Purpose Drug Purpose Drug Purpose Drug Purpose PLEASE ADVISE US IN THE FUTURE OF ANY CHANGE IN YOUR MEDICAL HISTORY OR ANY MEDICATIONS YOU MAY BE TAKING.Patient's signatureCAPTCHAEmailThis field is for validation purposes and should be left unchanged.
