Medical Information

Last name

First name

Birthday

Month

Day

Year

Are you in good health?

Has there been any change in your general health within the past year?

If yes, what is/ are the condition(s) being treated?

Date of last physical examination

Physician

Have you had any serious illness, operation, or been hospitalized in the past 5 years?

If yes, what was the illness or problem?

Are you taking or have you recently taken any medicine(s) including non-prescription medicine?

Prescribed

Over the Counter

Vitamins, natural or herbal preparations and/ or diet supplements:

Do you drink alcoholic beverages?

If yes, how much alcohol did you drink in the last 24 hours?

In the past week?

Do you use drugs or other substances for recreational purposes?

If yes, please list

Frequency of use (daily, weekly, etc.)

Do you use tobacco or nicotine products (smoking, snuff, chew, vaping, Zyn, etc.)?

If yes, how interested are you in stopping?

Do you wear contact lenses?

Food allergy (specify)

Metals allergy (specify)

Other allergy (specify)

To yes responses, specify type of reaction

Have you had an orthopedic total joint (hip, knee, elbow, finger) replacement?

If yes, when was this operation done?

If you answered yes to the above question, have you had any complications or difficulties with your prosthetic joint? Please Explain

Has a physician or previous dentist recommended that you take antibiotics prior to your dental treatment?

If yes, what antibiotic and dose?

Name of physician or dentist?

(Women only) Are you or could you be pregnant?

(Women only) Are you nursing?

(Women only) Are you taking birth control or hormonal replacement?

If you checked yes to Diabetes, specify type below

What was your last HBA1C?

Do you have any disease, condition, or problem not listed above that you think I should know about? Please explain

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