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

If under the care of a physician, please elaborate on why, provide PCP`s name and date of last exam.Not seeing physician.Sickle Cell DiseaseRadition to the head/neckI use osteoporosis medications.AnemiaCold Sores/Fever BlistersBlood transfusionPsychiatric careUse Tobacco ProductsAIDS/HIVBlood diseaseDiabetesCongenital Heart DiseaseSinus TroubleChemotherapy/Cancer TxBy checing the box, it will indicate a YES response; leaving blank will indicate a NO response. Check all that apply.Mitral valve prolapseADD/ADHDI pre-medicate for dental procedures.TonsillitusLiver diseaseList any allergies to medications or other substances.Heart MurmurMigraine/severe headachesCortisone TreatmentsList any medications you are currently taking.GlaucomaI feel like I am in good health.AsthmaPatient Signature:____________________________________________________________ Date: 12/3/2024Blood Pressure Issues (High/Low)Artificial JointsTuberculosisFainting or dizzinessCirculatory problemsEpilepsy/SeizuresDiet (special/restricted)Abnormal bleeding with dental txThyroid problemsStrokeHepatitis Type A, B, C, OtherTumor/growth on head/neckSnore loudlyTMJ IssuesArtificial Heart ValvesChronic painAnxietyI use blood thinners or aspirin.PacemakerHay Fever/HivesEmphysemaGastrointestinal DiseaseRadiation TreatmentParkinson`s DiseaseList Osteoporosis Medication (Bisphosphonates examples: Fosamax, Actonel, Boniva)CancerHeart ProblemsRheumatic FeverArthritis/RheumatismBloody coughKidney diseaseList IV Medication (Denosumab, pamidronate zolendronate):Chemical dependencyTaking Birth Control (list in medications)Trying to get pregnant (invitro)Have you had any serious illnesses or have been hospitalized in the past 5 years? Explain below.Medical History UpdateCurrently nursingWOMEN ONLY:Explain your need to premedicate: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)