Medical History - Dental Oasis



MEDICAL HISTORYPATIENT NAME (Please print): ____________________________________________________________________ Patient Date of Birth: _________________________Physician’s name: ________________________________________________________________________________ Physician’s phone #: __________________________Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions.Are you under a physician’s care now?Ο Yes Ο No If yes, please explain: ___________________________________________________Have you ever been hospitalized or had a major operation?Ο Yes Ο No If yes, please explain: ___________________________________________________Have you ever had a serious head or neck injury?Ο Yes Ο No If yes, please explain: ___________________________________________________Are you taking any medications, pills, or drugs?Ο Yes Ο No If yes, please list: _______________________________________________________Do you take, or have you taken, Phen-Fen or Redux?Ο Yes Ο No _____________________________________________________________________Are you on a special diet?Ο Yes Ο No _____________________________________________________________________Do you smoke or use tobacco? Ο Yes Ο NoDo you use controlled substances?Ο Yes Ο NoAre you allergic to any of the following? □ Yes □ No□ Acrylic □ Aspirin □ Codeine □ Erythromycin □ Jewelry □ Latex □ Local Anesthetics □ Metals □ Penicillin □ Tetracycline □ OtherIf yes, please explain: ______________________________________________________________________________________________________________________________Women: Are youPregnant/Trying to get pregnant? Ο Yes Ο No If pregnant, how many weeks / months? _______ Taking Oral Contraceptives? Ο Yes Ο No Nursing? Ο Yes Ο No Do you have, or have you had any of the following?AIDS/HIV PositiveΟ Yes Ο No Alzheimer’s DiseaseΟ Yes Ο No AnaphylaxisΟ Yes Ο No AnemiaΟ Yes Ο No AnginaΟ Yes Ο No Arthritis/GoutΟ Yes Ο No Artificial Heart ValveΟ Yes Ο No Artificial JointΟ Yes Ο No AsthmaΟ Yes Ο No Blood DiseaseΟ Yes Ο No Blood TransfusionΟ Yes Ο No Breathing ProblemΟ Yes Ο No Bruise EasilyΟ Yes Ο No CancerΟ Yes Ο No ChemotherapyΟ Yes Ο No Chest PainsΟ Yes Ο No Cold Sores/Fever BlistersΟ Yes Ο No Congenital Heart Disorder Ο Yes Ο No ConvulsionsΟ Yes Ο No Cortisone MedicineΟ Yes Ο No DiabetesΟ Yes Ο No Drug AddictionΟ Yes Ο No Easily WindedΟ Yes Ο No EmphysemaΟ Yes Ο No Epilepsy or SeizuresΟ Yes Ο No Excessive BleedingΟ Yes Ο No Excessive ThirstΟ Yes Ο No Fainting Spells/DizzinessΟ Yes Ο No Frequent CoughΟ Yes Ο No Frequent DiarrheaΟ Yes Ο No Frequent HeadachesΟ Yes Ο No Genital HerpesΟ Yes Ο No GlaucomaΟ Yes Ο No Hay FeverΟ Yes Ο No Heart Attack/FailureΟ Yes Ο No Heart MurmurΟ Yes Ο No Heart Pace MakerΟ Yes Ο No Heart Trouble/DiseaseΟ Yes Ο No HemophiliaΟ Yes Ο No Hepatitis AΟ Yes Ο No Hepatitis B or CΟ Yes Ο No HerpesΟ Yes Ο No High Blood PressureΟ Yes Ο No Hives or RashΟ Yes Ο No HypoglycemiaΟ Yes Ο No Irregular HeartbeatΟ Yes Ο No Kidney ProblemsΟ Yes Ο No LeukemiaΟ Yes Ο No Liver DiseaseΟ Yes Ο No Low Blood PressureΟ Yes Ο No Lung DiseaseΟ Yes Ο No Mitral Valve ProlapseΟ Yes Ο No Pain in JointsΟ Yes Ο No Parathyroid DiseaseΟ Yes Ο No Psychiatric CareΟ Yes Ο No Radiation TreatmentsΟ Yes Ο No Recent Weight LossΟ Yes Ο NoRenal DialysisΟ Yes Ο No Rheumatic Fever Ο Yes Ο No Scarlet FeverΟ Yes Ο No ShinglesΟ Yes Ο No Sickle Cell DiseaseΟ Yes Ο No Sinus TroubleΟ Yes Ο No Spina BifidaΟ Yes Ο No Stomach/Intestinal DiseaseΟ Yes Ο No StrokeΟ Yes Ο No Swelling of LimbsΟ Yes Ο No Thyroid DiseaseΟ Yes Ο No TonsillitisΟ Yes Ο No TuberculosisΟ Yes Ο No Tumors or GrowthsΟ Yes Ο No UlcersΟ Yes Ο No Venereal DiseaseΟ Yes Ο No Yellow JaundiceΟ Yes Ο No Have you ever had any serious illness not listed above? Ο Yes Ο No If yes, please explain: __________________________________________________________________________________________________________________________________________________________________________________________________Comments:___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient’s) health. It is my responsibility to inform the dental office of any changes in medical status.SIGNATURE OF PATIENT, PARENT, or GUARDIAN ________________________________________________________ DATE __________________________ ................
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