New EHR Medical History

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New EHR Medical History

Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you maybe taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions.

Patient Details

Patient Name

Birth Date

Date Created

Primary care physician's name/number!

Preferred Pharmacy Name, Location, Number

Ethnic /Race (both needed for EHR)

When was the last time you were hospitalized or had a major operation

Have you ever had a serious head or neck injury*

Serious head or neck injury*

Are you taking any medications, pills, or drugs?

Medications, pills, or drugs?

Do you take, or have you taken, Phen- Fen or Redux+

Phen- Fen or Redux+

Have you ever taken Fosamax, Boniva, Actonel or

Fosamax, Boniva, Actonel or any other medications containing bisphosphonates*

Are you on a special diet?

Do you use tobacco?

Women: Are you...

Pregnant/Tryng to get pregnant? Nursing Taking oral contraceptives?

Are you allergic to any of the following? Aspirin Penicillin Codeine Acrylic Metal Latex Sulfa Drugs Local Anesthetics

Do you use controlled substances?

Other

Do you have, or have you had, any of the following?

Do you have, or have you had, any of the following? AIDS/HIV Positive Alzheimer's Disease Anaphylaxis Anemia Angina Arthritis/Gout Artificial Heart Valve Artificial Joint Asthma Blood Disease Frequent Diarrhea Frequent Headaches Low blood Pressure Lung Disease Mitral Valve Prolapse Osteoporosis Pain in jaw Joints Parathyroid Disease Psychiatric Care Cortisone Medicine Diabetes Drug Addiction Easily Winded Emphysema Epilepsy or Seizures Excessive Bleeding Excessive Thirst Fainting Spells/Dizziness Frequent Cough Leukemia Liver Disease Swelling of Limbs Thyroid Disease Tonsillitis Tuberculosis Tumors or growths Ulcers Venereal Disease Hemophilia Hepatitis A Hepatitis B or C Herpes High Blood Pressure High Cholesterol Hives or Rash Hypoglycemia Irregular Heartbeat Kidney Problems stomach/lntestinal Disease Stroke Cancer Chemotherapy Chest Pains Cold Sores/Fever Blisters Congenital Heart Disorder Convulsions Yellow jaundice Radiation Treatments Recent Weight Loss Renal Dialysis Rheumatic Fever Rheumatism Scarlet Fever shingles sickle Cell Disease sinus Trouble Blood Transfusion Breathing Problems Bruise Easily Glaucoma Hay Fever Heart Attack/Failure Heart Murmur Heart Pacemaker Heart Trouble/Disease

Have you ever had any serious illness not listed

Signatures

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient’s) health. It is my responsibility to inform the dental office of any changes in medical status.

Signature of Patient. Parent or Guardian:

Date Of Signature of Patient. Parent or Guardian

Signature of Dentist/Assistant:

Date Of Signature of Dentist/Assistant