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:

1. Hospitalization for illness or injury

Yes No

2. 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

3. Heart problems, or cardiac stent within the last six months

Yes No

4. History of infective endocarditis

Yes No

5. Artificial heart valve, repaired heart defect (PFO)

Yes No

6. Pacemaker or implantable defibrillator

Yes No

7. Orthopedic implant (joint replacement)

Yes No

8. Rheumatic or scarlet fever

Yes No

9. High or low blood pressure

Yes No

10. A stroke (taking blood thinners)

Yes No

11. Anemia or other blood disorder

Yes No

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

Yes No

13. Pneumonia, emphysema, shortness of breath, sarcoidosis

Yes No

14. Tuberculosis, measles, chicken pox

Yes No

15. Asthma

Yes No

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

Yes No

17. Kidney disease

Yes No

18. Liver disease

Yes No

19. Jaundice

Yes No

20. Thyroid, parathyroid disease, or calcium deficiency

Yes No

21. Hormone deficiency

Yes No

22. High cholesterol or taking statin drugs

Yes No

23. Diabetes

Yes No

HbA1c=

24. Stomach or duodenal ulcer

Yes No

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

Yes No

26. Osteoporosis/osteopenia i.e. taking bisphosphonates

Yes No

27. Arthritis

Yes No

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

Yes No

29. Glaucoma

Yes No

30. Contact Lenses

Yes No

31. Head or neck injuries

Yes No

32. Epilepsy/Convulsions (seizures)

Yes No

33. Neurologic disorders ADD/ADHD, Prion disease

Yes No

34. Viral infections and cold sores

Yes No

35. Any lumps or swelling in the mouth

Yes No

36. Hives, skin rash, hay fever

Yes No

37. STI/STD/HPV

Yes No

38. Hepatitis

Yes No

Type

39. HIV/AIDS

Yes No

40. Tumor, abnormal growth

Yes No

41. Radiation therapy

Yes No

42. Chemotherapy, immunosuppressive medication

Yes No

43. Emotional difficulties

Yes No

44. Psychiatric treatment

Yes No

45. Antidepressant medication

Yes No

46. Alcohol/Recreational drug use

Yes No

ARE YOU:

47. Presently being treated for any other illness

Yes No

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

Yes No

49. Taking medication for weight management

Yes No

50. Taking dietary supplements

Yes No

51. Often exhausted or fatigued

Yes No

52. Experiencing frequent headaches

Yes No

53. A smoker, smoked previously or use smokeless tobacco

Yes No

55. Often unhappy or depressed

Yes No

56. Taking birth control pills

Yes No

57. Currently pregnant

Yes No

58. 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.