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Princess Dental Existing Patient Medical History Update Form
Patient Name
*
DOB
*
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Physician
*
Physician’s Office Phone
*
PLEASE ANSWER YES OR NO TO THE FOLLOWING:
1. Are you currently under any medical treatment?
*
Yes
No
2. Have you been admitted to a hospital or needed emergency care during the past two years?
*
Yes
No
3. Are you currently taking any medications, including over-the-counter medications?
*
Yes
No
If yes to medications, please list
*
4. Have you ever had any complications following dental treatment?
*
Yes
No
5. Do you have or have had any of the following? Please check all that apply.
*
AIDS/HIV
Anemia
Arthritis
Artificial Joints
Asthma
Blood Disease
Cancer
Diabetes
Dizziness
Drug/Alcohol Dependency
Epilepsy
Excessive Bleeding
Fainting
Glaucoma
Head Injuries
Heart Disease/Angina
Heart Murmur
Hepatitis
High Blood Pressure
Kidney Disease
Liver Disease
Mental Disorders
Pacemaker
Radiation Therapy
Respiratory Problems
Rheumatic Fever
Rheumatism
Sinus Problems
Stomach Problems
Stroke
Tuberculosis
Thyroid Disease
Tumors
Venereal Disease
Smoker
Osteoporosis Medications
(e.g. Fosamax, Actone)
None of These
6. Are there any conditions or diseases not listed above that you have or ever had?
*
Yes
No
If yes to other conditions or diseases, please list
*
7. Are there any diseases or medical problems that run in your family? (e.g. diabetes, cancer, or heart disease)
*
Yes
No
If yes to diseases or medical problems that run in your family, please list
*
8. Do you have a history of snoring/sleep apnea?
*
Yes
No
If so do you use a mouth breather?
*
Yes
No
Do you often find it difficult to breathe through your nose?
*
Yes
No
Do you use a CPAP machine?
*
Yes
No
9. WOMEN ONLY: Are you breastfeeding?
Yes
No
10. Are you pregnant?
Yes
No
11. What is your due date?
*
12. Do you have any allergies to medications?
*
Yes
No
If yes to allergies to any medications, please list
*
13. Are you a sedation patient?
*
Yes
No
For Sedation Patients Only
14. What is your height?
*
What is your weight?
*
15. Do you have glaucoma?
*
Yes
No
16. Do you have an allergy to Benzodiazepines?
*
Yes
No
17. Have you received treatment for alcohol or drug use?
*
Yes
No
18. Do you use narcotics or sedatives on a regular basis?
*
Yes
No
19. Do you use recreational drugs?
*
Yes
No
20. Is there any problem or medical condition that you wish to discuss in private only?
*
Yes
No
Signature (Patient, Parent, or Guardian)
*
clear
Date
*
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