Swanson Dental - Medical History Form
Swanson Dental - Medical History Form
Patient Name
Patient Name
*
First
Last
Nickname (if different than first name)
Email
*
Phone
Phone
-
###
-
###
####
Age
*
Name of Physician/and their specialty
Most recent physical examination
Most recent physical examination
*
/
MM
/
DD
YYYY
Purpose of most recent physical examination
What is your estimate of your general health?
*
Excellent
Good
Fair
Poor
DO YOU HAVE or HAVE YOU EVER HAD:
1. Hospitalization for illness or injury
*
YES
NO
2. An allergic or bad reaction to any of the following:
2. An allergic or bad reaction to any of the following:
aspirin, ibuprofen, acetaminophen, codeine
penicillin
erythromycin
tetracycline
sulfa
local anesthetic
flouride
metal(s)
latex
nuts
fruit
other
Other allergic reaction
Allergy Details
3. Heart problems, or cardiac stent within the last six months
*
YES
NO
4. History of infective endocarditis
*
YES
NO
5. Artificial heart valve, repaired heart defect (PFO)
*
YES
NO
6. Pacemaker or implantable defibrillator
*
YES
NO
7. Orthopedic implant (joint replacement)
*
YES
NO
7A. Do you take a premedication prior to dental procedures?
*
YES
NO
8. Rheumatic or scarlet fever
*
YES
NO
9. High or low blood pressure
*
YES
NO
10. A stroke (taking blood thinner)
*
YES
NO
11. Anemia or other blood disorder
*
YES
NO
12. Prolonged bleeding due to a slight cut (INR > 3.5)
*
YES
NO
13. Pneumonia, emphysema, shortness of breath, sarcoidosis
*
YES
NO
14. Tuberculosis, measles, chicken pox
*
YES
NO
15. Asthma
*
YES
NO
16. Breathing or sleep problems (i.e. sleep apnea, snoring, sinus)
*
YES
NO
17. Kidney disease
*
YES
NO
18. Liver disease
*
YES
NO
19. Jaundice
*
YES
NO
20. Thyroid, parathyroid disease, or calcium deficiency
*
YES
NO
21. Hormone deficiency
*
YES
NO
22. High cholesterol or taking statin drugs
*
YES
NO
23. Diabetes
*
YES
NO
HbA1c =
24. Stomach or duodenal ulcer
*
YES
NO
25. Digestive or eating disorders (e.g. celiac disease, gastric reflux, bulimia, anorexia)
*
YES
NO
26. Osteoporosis/osteopenia (i.e. taking bisphosphonates)
*
YES
NO
27. Arthritis
*
YES
NO
28. Autoimmune disease (i.e. rheumatoid arthritis, lupus, scleroderma)
*
YES
NO
29. Glaucoma
*
YES
NO
30. Contact lenses
*
YES
NO
31. Head or neck injuries
*
YES
NO
32. Epilepsy, convulsions (seizures)
*
YES
NO
33. Neurologic disorders (ADD/ADHD, prion disease)
*
YES
NO
34. Viral infections and cold sores
*
YES
NO
35. Any lumps or swelling in the mouth
*
YES
NO
36. Hives, skin rash, hay fever
*
YES
NO
37. STI/STD/HPV
*
YES
NO
38. Hepatitis
*
YES
NO
39. HIV/AIDS
*
YES
NO
40. Tumor, abnormal growth
*
YES
NO
41. Radiation therapy
*
YES
NO
42. Chemotherapy, immunosuppressive medication
*
YES
NO
43. Emotional difficulties
*
YES
NO
44. Psychiatric treatment
*
YES
NO
45. Antidepressant medication
*
YES
NO
46. Alcohol/recreatoional drug use
*
YES
NO
ARE YOU:
47. Presently being treated for any other illness
*
YES
NO
48. Aware of a change in your health in the last 24 hours (i.e. fever, chills, new cough, or diarrhea)
*
YES
NO
49. Taking medication for weight management
*
YES
NO
50. Taking dietary supplements
*
YES
NO
51. Often exhausted or fatigued
*
YES
NO
52. Experiencing frequent headaches
*
YES
NO
53. A smoker, smoked previously or use smokeless tobacco
*
YES
NO
54. Considered a touchy/sensitive person
*
YES
NO
55. Often unhappy or depressed
*
YES
NO
56. Taking birth control pills
*
YES
NO
57. Currently pregnant
*
YES
NO
58. Diagnosed with a prostate disorder
*
YES
NO
Describe any current medical treatment, impending surgery, genetic/development delay, or other treatment that may possibly affect your dental treatment.
(i.e. Botox, Collagen Injections)
Describe any details regarding any question you answered YES to.
LIST ALL MEDICATIONS, SUPPLEMENTS, AND/OR VITAMINS TAKEN WITHIN THE LAST TWO YEARS
DRUG & PURPOSE
Drug Name - Purpose of Drug Drug Name - Purpose of Drug
PATIENT'S SIGNATURE
*
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or
Type
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Full Name
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