Medical History

Name *

Last name *

Phone *

Name of your general practitioner

Have you received medical treatment in the last two years? Please describe it:

Have you taken any medication during the last two years?

Yes

Have you taken any psychoactive substances or narcotics during the last two years?

Yes

Have you had a medical examination for heart problems before? Please describe when:

Have you been hospitalized?

Yes

Have you taken medication for bone loss?

Yes

Have you had an allergic (or adverse) reaction to any substance or medication? Please specify:

Please indicate which of the following you have had or currently have. Mark YES or NO for each item:

Heart (surgery, heart attack, disease)

Yes

Chest pain

Yes

Congenital heart disease

Yes

High or Low Pressure

Yes

Mitral valve prolapse

Yes

Artificial heart valve or pacemaker

Yes

Rheumatic fever

Yes

Arthritis / rheumatism

Yes

Cortisone medicine

Yes

Swollen ankles

Yes

Strokes

Yes

Special/Restricted Diet

Yes

Kidney problems

Yes

Artificial joints (hip, knee, etc.)

Yes

Ulcers

Yes

Diabetes

Yes

Thyroid problems

Yes

Glaucoma

Yes

Contact lenses

Yes

Pulmonary emphysema

Yes

Chronic cough

Yes

Tuberculosis

Yes

Asthma

Yes

Hay fever / hives

Yes

Latex allergy

Yes

Sinusitis

Yes

Radiotherapy

Yes

Chemotherapy

Yes

Tumors

Yes

Hepatitis

Yes

Venereal disease

Yes

AIDS or HIV positive

Yes

Cold sores

Yes

Transfusions

Yes

Hemophilia

Yes

Bruises

Yes

Jaundice

Yes

Neurological disorders

Yes

Epilepsy

Yes

Fainting or dizziness

Yes

Nervousness or anxiety

Yes

Psychiatric care

Yes

Do you have or have you had any other illnesses, conditions, or problems not mentioned?

If yes, please specify:

Are you pregnant or do you think you might be? If so, how many months along are you?

Breastfeeding?

Yes

Did you use any contraceptive method?

Yes

I understand that the above information is necessary to provide me with safe and efficient dental care. I have answered all questions to the best of my knowledge, and I will notify you of any changes in my health or medication. In case of emergency, you have my permission to contact my general practitioner or specialist and are authorized to release information if there is a valid medical reason.