YEARLY MEDICAL HISTORY FORM PATIENT'S NAME * First Name Last Name PREFERRED NAME * Has there been any changes in your health status since your last visit? * Hospitalizations Medications Surgeries Other None IF CHECKED ANY OF THE ABOVE, PLEASE EXPLAIN: CHECK ANY OF THE CONDITIONS BELOW THAT YOU HAVE EXPERIENCED: * *Allergy Not listed *No Epinephrine .Alzheimer's disease .Dementia Acid Reflux a-Fib Allergy - Latex Allergy- Codeine Allergy Metal Allergy- Penicillin Allergy- Sulfa Allergy-Aspirin Allergy-Tetracyclin Anemia Anxiety Arthritis Arthritis-Rheumatoid Artificial Joints Aspirin Therapy Asthma Birth Control Med Birth Control Meds Bleeding easily Blood Disease Blood Pressure-High Blood Pressure-low Blood Thinner Cancer Chemotherpy Chronic Cough Chronic Fatigue Chronic Pain Colitis/Chron's/IBS COPD COVID19 CPAP Depression Diabetes Dizziness Epilepsy Fainting Fibromyalgia Glaucoma Hay Fever Headache/migraine Hearing loss Heart attack Heart Defects Heart Disease Heart Murmur Heart pacemaker Heart palpations Heart stents placed Heart valuve replace Hepatitis Herpes/Fever Blister High Cholesterol HIV+/AIDS hormone replacement Hyper Active/ADD Insomnia Intestinal disorder Kidney Disease Liver Disease Lupus Medication OTC Medication Prescribe Mental Disorders Mitral ValveProlapse Nervous Disorders Osteoporosis Pregnant Radiation Treatment Rheumatic Fever Seizures Shortness of breath Sinus Problems Sleep Disorder/Apnea Smoke/Vape/Chew Snoring Stroke Substance Abuse Thyroid Disease TMJD- jaw pain Tuberculosis Tumors/Growths Ulcers Please list any medications you are currently taking, one medication per line: * Please list anything additional that causes allergic reactions: * Please list any serious or ongoing medical condition(s): * Physicians Name, Phone # and date last physical exam: * Are you currently under the care of a physician? * YES NO IF YES, PLEASE EXPLAIN Have you ever taken Bone Replacement Therapy medications (i.e. Fosamax, Boniva, etc.)? * YES NO Have you ever taken Phen-Fen, Redux or Pondimin ( weightloss medication) ? If yes, see next question. * YES NO If yes, have you had a medical /cardiac evaluation? If so, what were the results? Additional notes & comments AUTHORIZATION * I affirm the information I have given is correct to the best of my knowledge, and that it is my responsibility to inform this office of any changes in my medical status. I authorize the dental staff to perform the necessary services I may need. I assign the Doctor all insurance benefits. I understand that I am responsible for payment of services rendered, any deductible, and co-payment that my insurance does not cover. By checking this box, I acknowledge that I have read this statement and agree to the contents. Thank you!
