Medical/Health History Form

Emergency Assistance

If this is an emergency, call:

Crisis Line: (513) 860-3660
911

Patient Information

First name

Last name

Nickname

Age

Name of Physician/and their specialty

Most recent physical examination

Purpose

What is your estimate of your general health?

Excellent

Good

Fair

Poor

Emergency Contact Information

Add emergency contact

Medical History

DO YOU HAVE or HAVE YOU EVER HAD:

Hospitalization for illness or injury

Yes No

An allergic or bad reaction to any of the following:

aspirin, ibuprofen, acetaminophen, codeine

penicillin

erythromycin

tetracycline

sulfa

local anesthetic

fluoride

metals

Metal Allergies

latex

nuts

Nut Allergies

fruit

other

Fruit Allergies

Other Allergies

Heart problems, or cardiac stent within the last six months

Yes No

Artificial heart valve, repaired heart defect (PFO)

Yes No

History of infective endocarditis

Yes No

Pacemaker or implantable defibrillator

Yes No

Orthopedic implant (joint replacement)

Yes No

Rheumatic or scarlet fever

Yes No

High or low blood pressure

Yes No

A stroke (taking blood thinners)

Yes No

Anemia or other blood disorder

Yes No

Prolonged bleeding due to a slight cut (INR > 3.5)

Yes No

Pneumonia, emphysema, shortness of breath, sarcoidosis

Yes No

Breathing or sleep problems (i.e. sleep apnea, snoring, sinus)

Yes No

Asthma

Yes No

Tuberculosis, measles, chicken pox

Yes No

Kidney disease

Yes No

Liver disease

Yes No

Jaundice

Yes No

Thyroid, parathyroid disease, or calcium deficiency

Yes No

Hormone deficiency

Yes No

High cholesterol or taking statin drugs

Yes No

Diabetes

Yes No

HbA1c=

Osteoporosis/osteopenia i.e. taking bisphosphonates

Yes No

Arthritis

Yes No

Autoimmune disease i.e. rheumatoid arthritis, lupus, scleroderma

Yes No

Digestive or eating disorders e.g., celiac disease, gastric reflux, bulimia, anorexia

Yes No

Stomach or duodenal ulcer

Yes No

Glaucoma

Yes No

Contact Lenses

Yes No

Head or neck injuries

Yes No

Epilepsy/Convulsions (seizures)

Yes No

Neurologic disorders (ADD/ADHD, prion disease)

Yes No

Viral infections and cold sores

Yes No

Any lumps or swelling in the mouth

Yes No

Hives, skin rash, hay fever

Yes No

STI/STD/HPV

Yes No

Hepatitis

Yes No

Type

HIV/AIDS

Yes No

Tumor, abnormal growth

Yes No

Radiation therapy

Yes No

Chemotherapy, immunosuppressive medication

Yes No

Emotional difficulties

Yes No

Psychiatric treatment

Yes No

Antidepressant medication

Yes No

Alcohol/Recreational drug use

Yes No

ARE YOU:

Presently being treated for any other illness

Yes No

Aware of a change in your health in the last 24 hours (i.e. fever, chills, new cough, or diarrhea)

Yes No

Taking medication for weight management

Yes No

Taking dietary supplements

Yes No

Often exhausted or fatigued

Yes No

Experiencing frequent headaches

Yes No

A smoker, smoked previously or use smokeless tobacco

Yes No

Often unhappy or depressed

Yes No

Taking birth control pills

Yes No

Currently pregnant

Yes No

Diagnosed with a prostate disorder

Yes No

Describe any current medical treatment, impending surgery, genetic/development delay, or other treatment that may possibly affect your dental treatment. (i.e. Botox, Collagen Injections)

List all medications, supplements, and or vitamins taken within the last two years:

Add Medication/Supplement/Vitamin

PLEASE ADVISE US IN THE FUTURE OF ANY CHANGE IN YOUR MEDICAL HISTORY OR ANY MEDICATIONS YOU MAY BE TAKING.

Patient/Guardian Signature

Date

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Brown & Gettings, DDS

For over 37 years, Brown & Gettings, DDS has been providing high quality dental care to patients in the West Chester, Ohio and surrounding area. We treat our patients just like family and take special care to help you and your family prevent oral disease before it happens. We use cutting edge dental technology to assist us in treatments including crowns, bridges, dentures, implants, root canals, and clear adult braces. We also provide cosmetic dental services such as teeth whitening and veneers to help transform your smile. Our patients also rely on us to relieve them of sleep apnea and TMJ disorders. Whatever your family’s dental needs may be, we have the experience and expertise to help you achieve a healthy smile.