DRUG PURPOSE DRUG PURPOSE
1. hospitalizaon for illness or injury
2. an allergic reacon to:
aspirin, ibuprofen, acetaminophen, codeine
penicillin
erythromycin
tetracycline
sulfa
local anesthec
uoride
metals (nickel, gold, silver, ____________)
latex
other
3. heart problems, or cardiac stent within the last six months
4. history of infecve endocardis
5. arcial heart valve, repaired heart defect
6. pacemaker or implantable debrillator
7. orthopedic implant (joint replacement)
8. rheumac or scarlet fever
9. high blood pressure
10. a stroke
11. anemia or other blood disorder
12. prolonged bleeding due to a slight cut (INR > 3.5)
13. emphysema, shortness of breath, sarcoidosis
14. tuberculosis, measles, chicken pox
15. asthma
16. breathing or sleep problems (i.e. sleep apnea, snoring, sinus)
17. kidney disease
18. liver disease
19. jaundice
20. thyroid, parathyroid disease, or calcium deciency
21. hormone deciency
22. high cholesterol or taking stan drugs
23. diabetes (HbA1c =_______)
24. stomach or duodenal ulcer
25. digesve disorders (i.e. celiac disease, gastric reux)
26. osteoporosis/osteopenia (i.e. taking bisphosphonates)
27. arthris
28. autoimmune disease
(i.e. rheumatoid arthris, lupus, scleroderma)
29. glaucoma
30. head or neck injuries
31. epilepsy, convulsions (seizures)
32. neurologic disorders (ADD/ADHD, prion disease)
33. viral infecons and cold sores
34. any lumps or swelling in the mouth
35. hives, skin rash, hay fever
36. sexually tranismied disease, HIV, or HPV
37. hepas (type _______)
38. HIV / AIDS
39. tumor, abnormal growth
40. radiaon therapy
41. chemotherapy, immunosuppressive medicaon
42. psychiatric treatment
43. andepressant medicaon
44. alcohol / recreaonal drug use
ARE YOU:
45. presently being treated for any other illness
46. aware of a change in your health in the last 24 hours
(i.e. fever, chills, new cough, or diarrhea)
47. taking medicaon for weight management
48. taking dietary supplements
49. oen exhausted or fagued
50. experiencing frequent headaches
51. a smoker, smoked previously or use smokeless tobacco
52. oen unhappy or depressed
53. currently pregnant
Paent Name:
Medical History
10435 Illinois Road, Fort Wayne, IN 46814
Ph: (260)469-3671 | www.holmesfamilydenstry.com
Nickname: Age:
Name of Physician/and their specialty:
Most recent physical examinaon:
What is your esmate of your general health?
Purpose:
Excellent FairGood Poor
DO YOU HAVE or HAVE YOU EVER HAD: NO NOYES YES
Describe any current medical treatment, impending surgery, genec/development delay, or other treatment that may possibly aect your dental
treatment. (i.e. Botox, Collagen Injecons)
PLEASE ADVISE US IN THE FUTURE OF ANY CHANGE IN YOUR MEDICAL HISTORY OR ANY MEDICATIONS YOU MAY BE TAKING.
Paent’s Signature:
Doctor’s Signature:
Date:
Date:
LIST ALL MEDICATIONS, SUPPLEMENTS, AND OR VITAMINS TAKEN WITHIN THE LAST TWO YEARS.