Medical History and Consent

Although dental personnel treat the area in and around your mouth, your mouth is a part of your entire body. Health conditions or problem that you may have or had, or medications that you may be taking could have an important Interrelationship with the treatment you will receive. Thank you for answering the following questions.

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Allergies	GERD: YesNo	Neurological
Acrylics: YesNo	Soft or Special Diet: YesNo	Alzheimer’s Disease: YesNo
Anaphylaxis: YesNo	Ulcers: YesNo	Diziness: YesNo
Lalex: YesNo	Genitourinary	Fainting: YesNo
Local Areshthetics: YesNo	Frequent Urination: YesNo	Memory Loss: YesNo
Penicillin: YesNo	Kidney Disease: YesNo	Multiple Sclerosis: YesNo
Metal: YesNo	General	Muscle Weakness: YesNo
Sulpha: YesNo	Current Weight:	Seizures: YesNo
Other: YesNo	Height:	Stroke: YesNo
List other known allergies:	Cancer: YesNo	Tingling/ Numbness: YesNo
	Fatigue/ Tired: YesNo	Trigeminal Neuralgia: YesNo
	General Weakness: YesNo	Tremor: YesNo
	Headaches: YesNo	Psychiatric
	HIV/AIDS: YesNo	ADD/ADHD: YesNo
Cardiovascular	Knee/hip Replacement: YesNo	Anxiety: YesNo
Artificial Heart Valve: YesNo	Liver Problem: YesNo	Chemical Dependency: YesNo
Coronary Artery Disease: YesNo	Recent Trauma or Injury: YesNo	Depression: YesNo
Chest Pain or Angina: YesNo	Rheumatic Fever: YesNo	Eating Disorder: YesNo
Congestive Heart Failure: YesNo	Radiation Treatment: YesNo	Excessive Stress: YesNo
Heart AttackYesNo:	Weight Change: YesNo	Memory Problems: YesNo
Heart Murmur: YesNo	Hematological	Respiratory
High Blood Pressure: YesNo	Bleeding Problems: YesNo	Asthma: YesNo
High Cholesterol: YesNo	Hepatitis: YesNo	Bronchitis: YesNo
Irregular Heart Beat: YesNo	Oral	Breathing Problems: YesNo
Low Blood Pressure: YesNo	Bleeding gums: YesNo	Chest Pressure: YesNo
Mitral Valve Prolapse: YesNo	Dry Mouth: YesNo	Congestion: YesNo
Pacemaker: YesNo	Jaw Problems (TMJ)? YesNo	Dyspnea (shortness of breath): YesNo
Tachycardia: YesNo	Clicking? YesNo
Endocrine	Pain? YesNo	Emphysema: YesNo
Diabetes: YesNo	Difficulty Swallowing? YesNo	Orthopnea: YesNo
Goul: YesNo	Difficulty chewing? YesNo	Pneumonia: YesNo
Hormonal Charge: YesNo	Orthodontics/ Invisalign? YesNo	Pulmonary Embolism: YesNo
Thyroid Problem: YesNo	Periodonial Disease: YesNo	Tuberculosis: YesNo
Eyes, Ears, Nose, and Throat	Teeth Cleaning: YesNo	Sleep
Change in Hearing: YesNo	Teeth Grinding: YesNo	Daytime Sleepiness: YesNo
Change in Vision: YesNo	Tooth Pain: YesNo	Morning Headache: YesNo
Dysphagia: YesNo	Wisdom teeth extraction: YesNo	Obstructive Sleep Apnea: YesNo
Ear Pain: YesNo	Do you wear removable teeth: YesNo	Do you us a CPAP? How often? YesNo
Glaucoma: YesNo	Do you take or need antibiotics before dental procedures? YesNo	Has anyone told you that you snore? YesNo
Hay Fever: YesNo	Musculoskeletal	Social Health
Nasal Obstruction: YesNo	Back Pain: YesNo	Do you smoke? YesNo, Packs a day?
Nose Bleeding: YesNo	Fibromyalgia: YesNo	Do you use smokeless tobacco? YesNo
Sinus Problems: YesNo	Joint Pain: YesNo	Do you consume alcoholic beverages? YesNo, Drinks per day/ week/ Month:
Tonsilleclomy : YesNo		Do you recreational drugs? YesNo
Tinnitu (Ringing): YesNo
Gastrointestinal
Acid Reflux: YesNo