Medical History 2 * Dental History 1 * Office Polices 2 * Medical History Update 2 * 

WOMEN ONLY:Currently nursingMedical HistoryTrying to get pregnant (invitro)Have you had any serious illnesses or have been hospitalized in the past 5 years? Explain below.Taking Birth Control (list in medications)Chemical dependencyList IV Medication (Denosumab, pamidronate zolendronate):Kidney diseaseBloody coughArthritis/RheumatismRheumatic FeverHeart ProblemsCancerList Osteoporosis Medication (Bisphosphonates examples: Fosamax, Actonel, Boniva)Parkinson`s DiseaseRadiation TreatmentGastrointestinal DiseaseEmphysemaHay Fever/HivesPacemakerChronic painI use blood thinners or aspirin.AnxietyArtificial Heart ValvesTMJ IssuesTumor/growth on head/neckSnore loudlyStrokeExplain your need to premedicate:Diet (special/restricted)Abnormal bleeding with dental txThyroid problemsHepatitis Type A, B, C, OtherEpilepsy/SeizuresFainting or dizzinessCirculatory problemsArtificial JointsTuberculosisBlood Pressure Issues (High/Low)Patient Signature:____________________________________________________________ Date: 12/3/2024AsthmaI feel like I am in good health.List any medications you are currently taking.GlaucomaCortisone TreatmentsMigraine/severe headachesHeart MurmurList any allergies to medications or other substances.Liver diseaseTonsillitusI pre-medicate for dental procedures.ADD/ADHDMitral valve prolapseBy checing the box, it will indicate a YES response; leaving blank will indicate a NO response. Check all that apply.Chemotherapy/Cancer TxSinus TroubleCongenital Heart DiseaseDiabetesBlood diseaseAIDS/HIVPsychiatric careUse Tobacco ProductsBlood transfusionCold Sores/Fever BlistersAnemiaI use osteoporosis medications.Radition to the head/neckSickle Cell DiseaseNot seeing physician.If under the care of a physician, please elaborate on why, provide PCP`s name and date of last exam.No serious illness/hospitalizations in last 5 years.List the Pharmacy Name, Address and Phone Number you want prescriptions to be sent to:UlcerHormone replacement therapyCurrently pregnantI am using/used IV medications.Please elaborate on any problems checked above.Mouth breathingSleep ApneaUse CPAPHad sleep study last 2 yearsPlease describe or further explain any sleep apnea symptoms above.List any current treatment, impending surgery that may possibly affect your dental treatment.Stopped breathing, choke or gasp during sleepFatigued/sleepy during daytimeHeartburn/GERDBy checking this box, I acknolwedge that I have reviewed ALL questions/alerts on this questionnaire and responded accordingly.LupusMental disorders or depressionDate: 12/3/2024First Name:Last Name:Birthdate:I am aware that I must notify the practice of any future changes.Check all that apply.This will serve as my electronic signature.There are no other medical conditions or medications/allergies that have not been listedDoxycycline AllergyOther Allergy. List in box.Season Allergies or HivesCodeine AllergyMorphine AllergyOther medications not listed:Penicillin AllergyCipro AllergyBarbituates AllergyErythromycin AllergyNut AllergyLatex AllergySulfa AllergyList Blood Thinning Medication ( examples: Coumadin, Rivaroxaban, Clopidogrel)