Patient Name:
Natural Smiles Dentistry
Eaglesoft Medical History Birth Date: Date Created:
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 may be taking..
Are you under a physician's care now?
Ha'Je you eve.r been hospitalized or had a major ope.ration?
Have you ever had a serious head or neck injury?
Are.you taking any medications., pills, or drugs?
Do you take, or have you taken., Ph en-Fen or Redux?
Have you e.ver taken Fosamax, Boniva, Acton el or any other medications containing bisphosphonates?
Are. you on a special diet?
Do you use tobacco?
Do you use controlled substances?
Women: Are you ...
Oves QNo
QYes QNo
OYes QNo
QYes QNo
OYes QNo
Oves QNo
QYes QNo
OYes QNo
OYes QNo
D Pregnant/Trying to get pregnant> □ Nursing>
Are you allergic to any of the following?
□Aspirin D Penicillin
□ Metal □ Latex
Other? □
Do you have.r or have you had.r any of the follo•Ning?
AID S/H N Positive OYes QNo Cortisone Medicine OYes
Alzheimer's Disease QYes QNo Diabetes QYes
Anaphylaxis OYes QNo Drug Addiction OYes
Anemia Qves QNo Easily Winded QYes
Angina Oves QNo Emphysema Oves
Arthritis/Gout Qves QNo Epilepsy or Seizures QYes
Artificial HeartValve Oves QNo Excessive Bleeding Oves
Artificial Joint OYes QNo Excessive Thirst OYes
Asthma QYes QNo Fainting Spells/Dizziness QYes
Blood Disease OYes QNo Frequent Cough OYes
Blood Transfusion QYes QNo Frequent Diarrhea QYes
Breathing Problems Oves QNo Frequent Headaches Oves
Bruise Easity Qves QNo Genital Herpes QYes
Cancer Oves QNo Glaucoma Oves
Chemotherapy OYes QNo Hay Fe.ver OYes
Chest Pains QYes QNo H ea rtAttack/Fai lure QYes
Cold Sores/Fever Blisters OYes QNo Heart Murmur OYes
Congenital Heart Disorder QYes QNo Heart Pacemaker QYes
Convulsions Oves QNo H ea rtTrou b I e/Dis ease Oves
Have you ever had any serious illness not listed above? OYes QNo
Comments:
If yes
If yes
If yes
If yes
If yes
If yes
If yes
If yes
QNo
QNo
QNo
QNo
QNo
QNo
QNo
QNo
QNo
QNo
QNo
QNo
QNo
QNo
QNo
QNo
QNo
QNo
QNo
If yes
□ codeine
D Sulfa Drugs
Hemophilia
Hepatitis A
Hepatitis B or C
Herpes
High Blood Pressure
High Cholesterol
Hives or Rash
Hypo g lycernia
Irregular Heartbeat
Kidney Problems
Leukemia
Liver Disease
Low Blood Pressure.
Lung Disease
Mitra I Valve Prolapse
0 ste o porosis
Pain in Jaw Joints
Parathyroid Disease
Psychiatric Care
□Taking oral contraceptives?
□Acrylic
D Local Anesthetics
OYes QNo Radiation Treatments OYes QNo
QYes QNo RecentWe-ightloss QYes QNo
OYes QNo Renal Dialysis OYes QNo
QYes QNo Rheumatic Fever QYes QNo
Oves QNo Rheumatism Oves QNo
QYes QNo Scarlet Fever QYes QNo
Oves QNo Shingles Oves QNo
OYes QNo Sickle Cell Disease OYes QNo
QYes QNo Sinus Trouble- QYes QNo
OYes QNo Spina Bifida OYes QNo
QYes QNo stomach/Intestinal Disease QYes QNo
Oves QNo stroke Oves QNo
QYes QNo swelling oflimbs QYes QNo
Oves QNo Thyroid Disease Oves QNo
OYes QNo Tonsillitis OYes QNo
QYes QNo Tuberculosis QYes QNo
OYes QNo Tumors or Grov,ths OYes QNo
QYes QNo Ulcers QYes QNo
Oves QNo Venereal Disease Oves QNo
Ye.I low Jaundice. QYes QNo
To the best of my knowledge.r the questions on this form have been acrurately 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 stab.Js.
Signab.Jre of Patients
Parent or Guardian:
X Date: ____ _
