MEDICAL HISTORY

HAVE YOU EVER HAD
YES
NO
Periodontal disease/gum treatment
Orthodontic treatment
Do you snore?
Serious Injury to mouth or head
Discomfort in your jaw joint(TMJ/TMD)
Diagnosis of sleep apnea
1. Have you been under the care of a medical doctor during the past two years?
2. Are you taking or have you taken any medication or drugs in the past 2 years?
3. Have you ever taken Fen-Phen medications for weight loss (diet pill)?
If yes to the above, did you have a medical exam for heart issues:
4. Are you aware of having an allergic (or adverse) reactions to any medication or substance?
5. Do you use controlled substances?
6. Do you use tobacco?
7. Have you been a patient in the hospital during the past five years?
8. Indicate which of the following you have had or have at the present time:
Heart (Surgery, Disease, Attack)
Chest Pain/Atrial Fibrillation
Congenital Heart Disease
Heart Murmur
High Blood Pressure
Mitral Valve Prolapse
Artificial Heart Valve
Heart Pacemaker
Rheumatic Fever
Arthiritis/Rheumatism
Cortisone Medicine
Headaches
Stroke
Diet(Special Restricted)
Artificial Joints(hip, knee, etc)
Kidney Trouble
Ulcers
Diabetes
Thyroid Problem
Glaucoma
Recent Weight Loss
Emphysema
Chronic Cough
Tuberculosis
Asthma
Hay Fever
Latex Sensitivity
Allergies or Hives
Sinus Trouble
Radiation Therapy
Chemotherapy
Tumors
Hepatitis
Venereal Disease
A.I.D.S.
Cold Sores/Fever Blisters
Blood Transfusion
Hemophilia
Sickle Cell Disease
Bruise Easily
Liver Disease
Yellow Jaundice
Neurological Disorders
Epilepsy or Seizures
Fainting or Dizzy Spells
Nervous/Anxious
Psychiatric/Psychological Care
9. Do you have any disease, condition or problem not listed?
If yes, please list
10.Women. Are you:
Pregnant?
What month of your pregnancy are you in?
Nursing?
Taking birth control pills?