Medical History - Nicollet Station Dental

Patient Name *

Date of Birth *

Date Created

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 medications 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? *

Yes

Please supply details: *

Have you ever been hospitalized or had a major operation? *

Yes

Please supply details: *

Have you ever had a serious head or neck injury? *

Yes

Please supply details: *

Are you taking any medications, pills or drugs? *

Yes

Please supply details: *

Have you had Botox, Dermal filters or other facial cosmetic procedures? *

Yes

Date of procedure *

Please supply details: *

Are you on a special diet? *

Yes

Do you use tobacco? *

Yes

Type of tobacco used *

Do you use controlled substances? *

Yes

Please supply details: *

Women: Are you...

Pregnant/Trying to get pregnant?

Nursing?

Taking oral contraceptives?

Do you have or have you had any of the following?

AIDS/HIV Positive *

Yes

Cortisone Medicine *

Yes

Hemophilia *

Yes

Radiation Treatments *

Yes

Alzheimer's Disease *

Yes

Diabetes *

Yes

Hepatitis A *

Yes

Recent Weight Loss *

Yes

Anaphylaxis *

Yes

Drug Addiction *

Yes

Hepatitis B or C *

Yes

Renal Dialysis *

Yes

Anemia *

Yes

Easily Winded *

Yes

Herpes *

Yes

Rheumatic Fever *

Yes

Angina *

Yes

Emphysema *

Yes

High Blood Pressure *

Yes

Rheumatism *

Yes

Arthritis/Gout *

Yes

Epilepsy or Seizures *

Yes

High Cholesterol *

Yes

Scarlet Fever *

Yes

Artificial Heart Valve *

Yes

Excessive Bleeding *

Yes

Hives or Rash *

Yes

Shingles *

Yes

Artificial Joint *

Yes

Excessive Thirst *

Yes

Hypoglycemia *

Yes

Sickle Cell Disease *

Yes

Asthma *

Yes

Fainting Spells/Dizziness *

Yes

Irregular Heartbeat *

Yes

Sinus Trouble *

Yes

Blood Disease *

Yes

Frequent Cough *

Yes

Kidney Problems *

Yes

Spina Bifida *

Yes

Blood Transfusion *

Yes

Frequent Diarrhea *

Yes

Leukemia *

Yes

Stomach/Intestinal Disease *

Yes

Breathing Problems *

Yes

Frequent Headaches *

Yes

Liver Disease *

Yes

Stroke *

Yes

Bruise Easily *

Yes

Genital Herpes *

Yes

Low Blood Pressure *

Yes

Swelling of Limbs *

Yes

Cancer *

Yes

Glaucoma *

Yes

Lung Disease *

Yes

Thyroid Disease *

Yes

Chemotherapy *

Yes

Hay Fever *

Yes

Mitral Valve Prolapse *

Yes

Tonsillitis *

Yes

Chest Pains *

Yes

Heart Attack.Failure *

Yes

Osteoporosis *

Yes

Tuberculosis *

Yes

Cold Sores/Fever Blisters *

Yes

Heart Murmur *

Yes

Pain in Jaw Joints *

Yes

Tumors or Growths *

Yes

Congenital Heart Disorder *

Yes

Heart Pacemaker *

Yes

Parathyroid Disoirder *

Yes

Ulcers *

Yes

Convulsions *

Yes

Heart Trouble/Disease *

Yes

Psychiatric Care *

Yes

Venereal Disease *

Yes

Yellow Jaundice *

Yes

Eating Disorder *

Yes

Acid Reflux *

Yes

Have you ever had any serious illness not listed? *

Yes

Please provide details: *

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 treatment.

Signature *

Clear

Today's Date