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Medical History Form

 

The information provided on this form is important to your dental health. Please complete all of the questions to the best of your ability. If there have been any changes in your health, please tell us. Questions are welcome and appreciated.

 

The security of your information is very important to us. This form is fully secure and your information will be protected. To learn more about the security measures used on this form, click the security logo to the right.

 

Patient Information

 

Patient First Name: *

Patient Middle Name:

Patient Last Name: *

Date of birth: *

  

 

I. Select appropriate answer (leave blank if you do not understand the question)

 

Are you currently under the care of a physician? *

Yes No  

If so, for what condition?:

Have you gone to the hospital or ER, or had a serious illness in the last three years?

Yes No  

 

If YES, explain:

 

Have you ever had a serious head or neck injury?

Yes No  

If YES, explain:

 

Have you ever taken Fen-Phen?

Yes No  

If YES, when:

 

Are you on a special diet? If yes, please list:

 

Do you use tobacco?

Yes No  

 

II. Are you taking any medications, pills, or drugs?

Please check Yes/No for each

 

Please list all medications you are currently taking:

Supplements

Yes No  

Antibiotics

Yes No  

Bisphosphonate (Fosamax)

Yes No  

Bisphosphonate (Boniva)

Yes No  

Bisphosphonate (Actonel)

Yes No  

Other Bisphosphonates Not Listed

Yes No  

Alcohol

Yes No  

Corticosteriods

Yes No  

Weight loss medications

Yes No  

Over-the-counter medicines

Yes No  

Recreational drugs

Yes No  

 

III. Women only

Please check Yes/No for each

Are you or could you be pregnant?

Yes No  

If YES, what month?

Are you nursing?

Yes No  

Are you taking birth control pills?

Yes No  

 

IV. Are you allergic to or have you had a reaction to any of the following?

Please check Yes/No for each

Aspirin

Yes No  

Penicillin

Yes No  

Codeine

Yes No  

 

Acrylic

Yes No  

Metal

Yes No  

Latex

Yes No  

 

Sulfa Drugs

Yes No  

Local anesthetic (Novocain or Xylocaine)

Yes No  

 

 

Any other allergies not listed?

 

Do you use controlled substances? If yes, please list:

 
 

V. Do you have, or have you had, any of the following?

Please check Yes/No for each

AIDS/HIV Positive

Yes No  

Cortisone Medicine

Yes No  

Hemophilia

Yes No  

 

Radiation Treatments

Yes No  

Alzheimer's Disease

Yes No  

Diabetes

Yes No  

 

Hepatitis A

Yes No  

Recent significant weight loss

Yes No  

Anaphylaxis

Yes No  

 

Drug Addiction

Yes No  

Hepatitis B or C

Yes No  

Renal Dialysis

Yes No  

 

Arthritis, rheumatism

Yes No  

Anemia

Yes No  

Easily Winded

Yes No  

 

Herpes

Yes No  

Rheumatic fever

Yes No  

Chest pain (angina)

Yes No  

 

Emphysema or other lung disease

Yes No  

High blood pressure

Yes No  

Rheumatism

Yes No  

 

Arthritis/Gout

Yes No  

Epilepsy or Seizures

Yes No  

High Cholesterol

Yes No  

 

Scarlet Fever

Yes No  

Artificial Heart Valve

Yes No  

Excessive Bleeding

Yes No  

 

Hives or Rash

Yes No  

Shingles

Yes No  

Artificial joint

Yes No  

 

Excessive thirst

Yes No  

Hypoglycemia

Yes No  

Sickle Cell Disease

Yes No  

 

Asthma

Yes No  

Fainting Spells/Dizziness

Yes No  

Irregular Heartbeat

Yes No  

 

Sinus problems

Yes No  

Blood Disease

Yes No  

Persistent cough

Yes No  

 

Kidney or bladder disease

Yes No  

Spina Bifida

Yes No  

Blood Transfusion

Yes No  

 

Frequent Diarrhea

Yes No  

Leukemia

Yes No  

Stomach/Intestinal Disease

Yes No  

 

Breathing Problems

Yes No  

Frequent Headaches

Yes No  

Liver Disease

Yes No  

 

Stroke

Yes No  

Bruise easily

Yes No  

Low Blood Pressure

Yes No  

 

Swelling of Limbs

Yes No  

Cancer

Yes No  

Glaucoma

Yes No  

 

Lung Disease

Yes No  

Thyroid disease

Yes No  

Chemotherapy

Yes No  

 

Hay Fever

Yes No  

Mitral Valve Prolapse

Yes No  

Tonsilitis

Yes No  

 

Chest Pains

Yes No  

Heart Attack

Yes No  

Osteoporosis

Yes No  

 

Tuberculosis

Yes No  

Cold Sores/Fever Blisters

Yes No  

Heart murmurs

Yes No  

 

Pain in Jaw Joints

Yes No  

Tumors or Growths

Yes No  

Congenital Heart Disorder

Yes No  

 

Heart Pacemaker

Yes No  

Parathyroid Disease

Yes No  

Ulcers

Yes No  

 

Convulsions

Yes No  

Heart Trouble / Disease

Yes No  

Pyschiatric Care

Yes No  

 

Sexually transmitted disease

Yes No  

Yellow Jaundice

Yes No  

 

 

Have you ever had any serious illness not listed? If yes, please explain:

 

Is there any issue or condition that you would like to discuss with the dentist in private?

Yes No  

 

Certification of Information

 

I certify that I have read and understand this form. To the best of my knowledge, I have answered every question completely and accurately. I will inform my dentist of any change in my health and/or medication. Further, I will not hold my dentist, or any other member of his/her staff, responsible for any errors or omissions that I may have made in the completion of this form.

 

Signature of Patient/Guardian:

DATE:

 
 
 

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Frank Hsu, DDS
1553 Laurel St, Suite A,
San Carlos, CA 94070-5114
Phone: 650.262.1940
Fax: 650.592.1220
Email: frankhsu@sancarlosdental.com

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