Chad N. Allen, D.D.S. & Associates

MEDICAL HISTORY FORM Name: Date:

Date of Birth:______________ Age:______ Sex: M / F Height: Weight:

For the following questions, circle yes or no, whichever applies. Your answers are for ourrecords only and will be kept confidential.1. Are you in good health?..........................................................................................................Yes No2. Has there been any change in your health in the past year?.................................................Yes No3. My last physical exam was on / / 4. Are you now under the care of a physician?...........................................................................Yes No

If so, for what condition? ____________________________________________________5. List all name(s)/phone number(s) of your physician(s) (MD):_________________________

________________________________________________________________________The name of my dentist is ___________________________________________________6. Have you had any serious illness, operation or hospitalization within the past 5 years?.......Yes No7. Have you had an artificial joint replacement (knee, hip, shoulder, etc.)? ..............................Yes No8. Are you taking or have you ever taken Bisphosphonates for osteoporosis or

chemotherapy for multiple myeloma or other cancers (Reclast, Fosamax, Actonel, Boniva, Aredia, Zometa or Prolia) ? ......................................................................................

9. Are you taking any prescription medicine(s) including diet pills or non-prescription, vitamins,homeopathic or natural remedies?.........................................................................................Yes NoIf so, please list them on page 3. PLEASE write clearly.

10. Do you have or have you had any of the following diseases or problems? a. Damaged heart valves, artificial valves or heart murmur..................................................Yes No b. Rheumatic Heart Disease..................................................................................................Yes No c. Heart trouble, heart attack, angina, arteriosclerosis, coronary artery disease,

congestive heart failure or any other heart condition........................................................Yes No1. Chest pain upon exertion?...........................................................................................Yes No2. Shortness of breath after mild exercise?.....................................................................Yes No3. Do your ankles swell?..................................................................................................Yes No

d. High or low blood pressure................................................................................................Yes No e. Diabetes.............................................................................................................................Yes No f. Respiratory problems, emphysema, bronchitis, asthma, chronic cough..........................Yes Nog. Stroke or TIA (transient ischemic attack)..........................................................................Yes No h. Seasonal allergies ............................................................................................................Yes No i. Sinus disease or recurrent infections................................................................................Yes No j. Fainting spells or seizures.................................................................................................Yes Nok. Hepatitis, jaundice or liver disease....................................................................................Yes No l. Frequent or recurring mouth sores....................................................................................Yes Nom. Thyroid problems...............................................................................................................Yes No n. Arthritis or painful, swollen joints ......................................................................................Yes No o. Osteoporosis .....................................................................................................................Yes No p. Stomach ulcer or hyperacidity...........................................................................................Yes No q. Kidney trouble....................................................................................................................Yes No r. Tuberculosis......................................................................................................................Yes No s. Clenching, grinding teeth...................................................................................................Yes No t. Clicking or popping of the jaw joint (TMJ), pain near the ear, difficulty opening mouth....Yes No u. Epilepsy or neurological disorder......................................................................................Yes No v. Cancer...............................................................................................................................Yes No

w. Any disease such as AIDS or HIV positive, drug or transplant operation that has depressed your immune system.......................................................................................Yes No

x. Do you have dementia or Alzheimer’s disease……………………………………………... .Yes No11.Have you had abnormal bleeding?.........................................................................................Yes No

a. Have you ever required a blood transfusion?...................................................................Yes No12.Do you have any blood disorder such as anemia?.................................................................Yes No13.Have you ever had treatment for a tumor or growth? ............................................................Yes No14. Have you had radiation therapy to the head, neck or jaws?..................................................Yes No15.Are you allergic to or have you had a reaction to:

a. Local anesthetics...............................................................................................................Yes Nob. Penicillin or antibiotics.......................................................................................................Yes Noc. Sulfa drugs........................................................................................................................Yes Nod. Barbiturates or sleeping pills.............................................................................................Yes Noe. NSAIDs (motrin, ibuprofen, aleve).....................................................................................Yes Nof. Iodine.................................................................................................................................Yes Nog. Codeine or other narcotics................................................................................................Yes Noh. Latex or rubber products...................................................................................................Yes No

16.Have you had any serious trouble associated with previous dental treatment?....................Yes NoIf so, explain:

17.Do you have any other condition or disease you think the doctor should know about?........Yes NoIf so, explain:

18. Do you currently or have a history of smoking or chewing tobacco? ...................................Yes NoHow much? ____________________ Quit? ______________________

19. Do you use recreational drugs?.............................................................................................Yes NoIf so, please list______________________________________________________

20. Is there any past history of alcohol or chemical dependency or emotional disorder that may affect the care we provide you?...............................................................................Yes No

21. Are you wearing contact lenses?...........................................................................................Yes No22. Are you wearing removable dental appliances?....................................................................Yes No23. Do you wish to talk with the doctor privately about anything?...............................................Yes No

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Women24.Are you pregnant or trying to become pregnant.....................................................................Yes No25.Do you have problems associated with your menstrual period?............................................Yes No26.Are you nursing?.....................................................................................................................Yes No27.Are you taking birth control pills?............................................................................................Yes NoIf you are using Oral Contraceptives, it is important that you understand that antibiotics (and someother medications) may interfere with the effectiveness of oral contraceptives. Therefore, you will needto use mechanical forms of birth control for one complete cycle of birth control pills, after the course ofantibiotics or other medication is completed. Please consult with your physician for further guidance.

I have read and understand the above. Any questions I had about this form have been answered and Iunderstand the answers. I understand it is my responsibility to fill out the form correctly andcompletely.

Date: Patient or Guardian’s Signature:

Medications

Please clearly list all of your medications, including prescription and non-prescription:

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Allergies

Please clearly list all medication allergies and your reaction if known.

Medication Reaction (i.e., nausea, itching, rash, hives, anaphylaxis)

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Surgical History

Please clearly list previous surgeries where asleep (general anesthesia)

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