Medical History

Medical History

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MEDICAL HISTORY


Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body.  Health problemx that you may have, or medical that you may be taking, could have an important interrrelationship with the dentistry you will receive.  Thank you for answering the followint questions.



Yes
No
Yes
No


Yes
No
Yes
No
Yes
No

Acid Reflux
AIDS/HIV Positive
Alzheimer’s Disease
Anaphylaxis
Anemia
Angina
Arteriosclerosis
Arthritis/Gout
Artificial Heart Valve
Artificial Joint
Asthma
Autoimmune Disease
Blood Disease
Blood Transfusion
Breathing Problem
Bruise Easily
Cancer
Chemotherapy
Chest Pains
Cold Sores/Fever Blisters
Congenital Heart Disorder
Convulsions
Cortisone Medicine
Damaged Heart Valves
Diabetes
Drug Addition
Easily Winded
Emphysema
Epilepsy or Seizures
Excessive Bleeding
Excessive Thirst
Fainting Spells/Dizziness
Frequent Cough
Frequent Diarrhea
Frequent Headaches
Genital Herpes
Glaucoma
Hay Fever/Seasonal
Heart Attack/Failure
Heart Murmur
Heart Pacemaker
Heart Trouble/Disease
Hemophilia
Hepatitis
Hepatitis B or C
Herpes
High Blood Pressure
Hives or Rash
Hypoglycemia
Irregular Heartbeat
Kidney Problems
Leukemia
Liver Disease
Low Blood Pressure
Lung Disease
Mitral Valve Prolapse
Osteoporosis
Pain in Jaw Joints
Parathyroid Disease
Psychiatric Care
Radiation Treatments
Recent Weight Loss
Renal Dialysis
Rheumatic Fever
Rheumatism
Scarlet Fever
Shingles
Sickle Cell Disease
Sinus Trouble
Spina Bifida
Stomach/Intestinal Disease
Stroke
Swelling of Limbs
Thyroid Disease
Tonsillitis
Tumors or Growths
Uberculosis
Ulcers
Venereal Disease
Yellow Jaundice
Yes
No

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 status.



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