Medical History and Consent

    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.

     

    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


    Confidential

    Skyline Family Dentistry

    Gabriel Overholtzer D.D.S

     

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