Canyon park dental

MEDICAL HISTORY
Your Physician:________________________________ Type:________________________________ How Long:______________ Office Address:________________________________________________________ Phone:________________________________
DO YOU HAVE OR HAVE YOU EVER HAD: (circle)
1. Hospitalization for illness or surgery in last 5 years…………. Yes
27. Shortness of breath on mild exertion…………….Yes 2. An allergic reaction……………………………………………. Yes 28. Chest pains on mild exertion…………………….Yes 29. Hives, skin rash, hay fever………………………. Yes a. aspirin……………………………………………………… Yes 30. Glaucoma…………………………………………Yes b. penicillin…………………………………………………. Yes 31. Emotional problems or tension…………………. Yes c. erythromycin………………………………………………. Yes 32. Psychiatric treatment……………………………. Yes d. tetracycline………………………………………………… Yes 33. A tumor or abnormal growth……………………. Yes e. codeine……………………………………………………. Yes 34. Radiation treatment by cobalt, radium x-ray etc…. Yes f. sedatives or sleeping pills (barbiturates)………………. Yes 35. Oral piercings…………………………………… Yes g. dental anesthetic……………………………………………Yes 36. Jaw surgery (metal plates or screws) ……………Yes h. any other medication………………………………………. Yes No 37. Prostate disorders (If Male)……….………………Yes i. latex…………………………………………….……….Yes 38. AIDS (Acquired Immune Deficiency Syndrome). Yes 4. Hepatitis………………………………………………………. Yes 39. ARC or any AIDS related diseases………………. Yes 5. Jaundice (yellow skin and eyes)………………………………. Yes 40. Blood transfusion………………………………… Yes 6. Epilepsy……………………………………………………….Yes 41. Herpes(HSVI, HSVII)…………………………….Yes 7. Arthritis………………………………………………………. Yes 42. Cold sores or fever blisters……………………….Yes 8. Asthma…………………….…….…………………………. Yes 43. History of drug or alcohol abuse………………… Yes 9. Rheumatic fever………………………………………………. Yes 10. Scarlet fever…………………………………………………… Yes 11. Anemia or other blood disorders……………………………….Yes 1. Presently being treated for any illness……………. Yes 12. Prolonged bleeding due to a slight cut………………………… Yes 2. Now taking any medication………………………. Yes 13. Kidney disease………………………………………………… Yes 3. Aware of a change in you general health …………. Yes 14. Diabetes……………………………………………………….Yes 4. Aware of any recent weight change………………. Yes 15. Stomach disorder or Acid reflux….…………………………. Yes 5. Often thirsty………………………………………. Yes 16. Liver disease…………………………………………………. Yes 6. Urinating more than six times per day……………. Yes 17. Tuberculosis…………………………………………………… Yes 7. Often exhausted and fatigued……………………… Yes 18. Emphysema……………………………………………………. Yes 8. Subject to frequent headaches……………………. Yes 19. Thyroid or parathyroid disorders……………………………… Yes 9. Smoker, or using any tobacco products…………… Yes 20. Heart trouble…………………………………………………. Yes 10. Generally a nervous person………………………… Yes 21. Heart murmur…………………………………………………. Yes No 11. Often unhappy and depressed……………………… Yes 22. Arteriosclerosis………………………………………………….Yes 12. Taking any naturopathic meds or supplements…… Yes No 23. High blood pressure…………………………………………. Yes No 13. Taking aspirin or blood thinners…………………….Yes No 24. Low blood pressure…………………………………………… Yes 25. An artificial valve, pacemaker or joint placed …………………Yes No IF FEMALE, ARE YOU NOW:
26. A stroke………………………………………………………. Yes No 1. Pregnant or nursing……………………………….Yes 27. If “Yes” to 20, 21, 22, 23, 24, 25, or 26, have you discussed 2. Taking birth control pills or other hormones………Yes the need for pre-medicating or altering medications prior to
PLEASE EXPLAIN FULLY ANY “YES” ANSWERS ABOVE:

IF THERE ARE ANY CHANGES IN MY MEDICAL HISTORY, I WILL NOTIFY THE DENTIST.
Patient Signature: ________________________________________________ Today’s Date:________________________________

Medical History Update:
Date:
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Source: http://www.canyonparkdental.net/docs/Patient-Medical-HistoryMay2012.pdf