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: ____ _