Cochrane Dental Adult Medical History

Fill out the Adult Forms below and press the submit button after completing each form.
Please fill out the form in its entirety.

Please fill out one Adult Medical History form per patient.

PLEASE BE SURE TO REQUEST AN APPOINTMENT BEFORE COMPLETING THESE FORMS

Please select the form you wish to complete below.

Medical History Form

 

    MEDICAL HISTORY

    DO YOU HAVE or HAVE YOU EVER HAD:

    1. hospitalization for illness or injuryYESNO

    Please Specify

    2. an allergic or bad reaction to any of the following: YESNO

    3. heart problems, or cardiac stent within the last six monthsYESNO

    Select Date

    4. history of infective endocarditisYESNO

    5. artificial heart valve, repaired heart defect (PFO)YESNO

    Select Date

    6. pacemaker or implantable defibrillator YESNO

    Select Date

    7. joint replacement or heart valve replacement YESNO

    Select Date

    8. heart murmur, rheumatic or scarlet feverYESNO

    9. high blood pressureYESNO

    10. low blood pressureYESNO

    11. stroke (taking blood thinners)YESNO

    12. anemia or other blood disorder YESNO

    13. prolonged bleeding due toa slight cut (or INR greater than 3.5) YESNO

    14. pneumonia, emphysema, shortness of breath, sarcoidosis YESNO

    Please Specify

    15. chronic ear infections, tuberculosis, measles, chicken poxYESNO

    Please Specify

    16. breathing problems (e.g. asthma, stuffy nose, sinus congestion)YESNO

    Please Specify

    17. sleep problems (e.g. sleep apnea, snoring, insomnia or restless sleep) YESNO

    Please Select

    18. kidney diseaseYESNO

    19. liver disease or jaundice YESNO

    20. vertigo (e.g. ”the room is spinning”) YESNO

    21. thyroid, parathyroid disease, or calcium deficiency YESNO

    Please Specify

    22. hormone deficiency or imbalance (e.g. poly cystic ovarian syndrome) YESNO

    23. high cholesterol or taking statin drugs YESNO

    24. diabetesYESNO

    Please Specify

    25. stomach or duodenal ulcer or digestive or eating disorders (e.g. celiac disease, gastric reflux, bulimia, anorexia) YESNO

    Please Select

    26. osteoporosis/osteopenia or ever taken anti-resorptive medications (e.g. bisphosphonates) YESNO

    27. arthritis or gout YESNO

    Please Specify

    28. autoimmune disease (e.g. rheumatoid arthritis, lupus, scleroderma) YESNO

    Please Select

    29. glaucoma YESNO

    30. head or neck injuries YESNO

    31. epilepsy, convulsions (seizures) YESNO

    Please Specify

    32. neurologic disorders (ADD/ADHD, prion disease) YESNO

    33. viral infections and cold sores YESNO

    Please Specify

    34. any lumps or swelling in the mouth YESNO

    35. hives, skin rash, hay fever YESNO

    36. hepatitis (type YESNO

    37. HIV/AIDS YESNO

    38. tumor, abnormal growth YESNO

    39. radiation therapy YESNO

    Select Date

    40. chemotherapy, immunosuppressive medicationchemotherapy, immunosuppressive medication YESNO

    Select Date

    41. medication treatment or antidepressant medication (Autism, Sensory Issues, ADHD)YESNO

    Please Specify

    42. recreational drug use YESNO

    Please Specify Drug

    ARE YOU:

    43. presently being treated for any other illness YESNO

    Please Specify if any

    44. experiencing frequent headaches or chronic pain YESNO

    45. a smoker, smoked previously or other (smokeless tobacco, vaping, e-cigarettes, and cannabis) YESNO

    Please Specify

    46. currently pregnant YESNO

    47. diagnosed with a prostate disorder YESNO

    Describe any current medical treatment, impending surgery, genetic/development delay, or other treatment that may possibly affect your dental treatment. (i.e. Botox, Collagen Injections)

    Drug & Purpose 1

    Drug & Purpose 2

    Drug & Purpose 3

    Drug & Purpose 4

    PLEASE ADVISE US IN THE FUTURE OF ANY CHANGE IN YOUR MEDICAL HISTORY OR ANY MEDICATIONS YOU MAY BE TAKING.

    Thank you in advance from the Team at Cochrane Dental!