Allergic reaction to:
MEDICAL HISTORY
Patient Name ______________________________Nickname _____________________ Age _____________________
Name of Physician _______________________________________Most recent physical exam ____________________
HAVE YOU EVER HAD THE FOLLOWING
ALLERGIC REACTION TO: YES NO YES NO
Aspirin □ □ Diabetes □ □
Ibuprofen □ □ Stomach or Duodenal Ulcer □ □
Acetaminophen □ □ Digestive Disorders □ □
Penicillin □ □ Osteoporosis/Osteopenia □ □
Sulfa □ □ Arthritis □ □
Erythromycin □ □ Glaucoma □ □
Tetracycline □ □ Contact Lenses □ □
Codeine □ □ Head or Neck Injuries □ □
Local Anesthesia □ □ Epilepsy/Convulsions/Seizures □ □
Fluoride □ □ Viral Infections/Cold Sores □ □
Metals (gold, stainless steel) □ □ Any lumps/swelling in mouth □ □
Latex □ □ Hives/Skin Rash/Hay Fever □ □
Other medication _________ □ □ Venereal Disease □ □ Hospitalization for injury or illness □ □ HIV/AIDS □ □
Hepatitis □ □ Neurological Problems □ □
Heart Problems □ □ Cancer-type_____________ □ □
Heart Murmur □ □ Tumor/Abnormal Growth □ □
Rheumatic Fever □ □ Radiation Therapy □ □
Scarlet Fever □ □ Chemotherapy □ □
High Blood Pressure □ □ Emotional Problems □ □
Low Blood Pressure □ □ Alcohol/Drug Dependency □ □
Stroke □ □ High Cholesterol □ □
Artificial Prosthesis (joint or heart valve) □ □ Hormone Deficiency □ □
Thyroid or Parathyroid Disease □ □
Anemia/Blood Disorder □ □ ARE YOU:
Prolonged bleeding □ □ Taking antidepressant medication □ □
Emphysema □ □ Taking medication for weight control □ □
Tuberculosis □ □ Taking dietary supplements □ □
Asthma □ □ Subject to frequent headaches □ □
Sinus Problems □ □ A heavy smoker (1+ packs daily) □ □
Kidney Disease □ □ FEMALE-Taking birth control □ □
Liver Disease □ □ FEMALE-Pregnant □ □
Jaundice □ □ MALE-Prostate Disorder □ □
Describe any current medical condition, impending surgery, or other treatment that may affect dental treatment ________________________________________________________________________________________________
List medications, herbal supplements, and/or vitamins taken within the last 2 years ___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
PLEASE ADVISE US IN THE FUTURE OF ANY CHANGE IN YOUR MEDICAL HISTORY OR ANY MEDICATIONS YOU MAY BE TAKING.
Patient’s signature ___________________________________________________________________Date_____________________
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