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Archibald Dental Practice | Medical History in Ontario

 

  

Archibald Dental Practice

        Ingrid Mack Cruz D.D.S.                     Erick Esmenjaud D.D.S.

                                   Oscar Maldonado D.D.S.


call us (909) 947-0670

 

Family Dentistry

and Orthodontics

 

 (909) 947-0670

fax (909) 673-0527

[email protected]

 

Medical History

 

 

HEALTH HISTORY                                           Name_______________________________

 I.   Check Appropriate Answers: (Leave blank if you do not understand the question)

Yes     No    1.  Is your  general  health  good?_______________________________________________________

Yes    No    2. Has there been a change in your health within the last year?___________________________

Yes   No      3. Have you been hospitalized or had a serious illness in the last three years?_______________________

                    Please explain________________________________________________

       Yes  No      4. Are you being treated by a Physician now?___________________________________________________

                    Please explain_____________________________________________________________

                    Date of last general exam ____/_____/_______Date of last Dental exam____/____/____

                     5.   If yes to 4 above, name of  Medical Doctor___________________Phone Number (_____)__________

Yes  No       6.  Have you had  problems with prior dental  treatment?

                     Please explain___________________________________________________________________

       Yes   No     7. Are you in pain now ?    Explain_______________________________________________________________________________

        II.  Have You Experienced:

      YES    NO    8.    Chest pain (angina) ?                                                   YES     NO   19.  Dizziness?               

      YES    NO    9.   Swollen  ankles                                                            YES     NO   20. Ringing in the ears?

      YES    NO    10.    Shortness of breath?                                                   YES    NO    21.   Headaches?

      YES    NO    11.   Recent weight loss, fever,  night sweat?                          YES    NO    22. Fainting spells?

      YES    NO    12.   Persistent cough, Coughing up blood?                             YES    NO    23.  Blurred vision?

       YES   NO   13.   Bleeding problems, bruising easily?                                  YES    NO     24. Seizures?     

       YES   NO   14.  Sinus problems?                                                             YES    NO     25. Excessive thirst?

       YES   NO    15.  Difficulty swallowing ?                                                    YES    NO     26. Frequent urination?

       YES   NO    16.  Diarrhea, constipation, blood in stools ?                          YES    NO     27. Dry  mouth?

       YES   NO     17.  Frequent vomiting,  nausea?                                           YES    NO     28. Jaundice ?

       YES   NO     18.  Difficulty urinating, blood in urine ?                                   YES   NO    29. Joint pain, stiffness?

         III.  Do you Have Or Have You Had:

        YES    NO    30. Heart disease? Explain____________________               YES    NO    41. AIDS or ARC?

       YES   NO    31. Heart attack?   Explain____________________                 YES    NO    42.  HIV  positive

      YES   NO    32. Heart murmur?                                                                YES   NO    43.  VD (syphilis or  gonorrhea) ?

        YES   NO    33.High  Blood pressure?                                                        YES   NO   44.  Herpes?

        YES   NO    34.  Stroke, hardening of arteries?                                           YES  NO    45. Skin diseases?

       YES   NO    35. Rheumatic fever?                                                             YES   NO   46. Eye disease?            

         YES   NO    36.  TB, emphysema, other lung diseases?                               YES   NO   47. Anemia

         YES   NO    37.  Hepatitis, other liver disease?                                           YES   NO   48. Arthritis,  rheumatism?

         YES   NO   38.   Stomach  problems,  ulcers?                                           YES   NO   49. Kidney,  bladder disease?

         YES   NO    39.Allergies to: latex, food,  medications?_________                 YES   NO    50.Thyroid,  adrenal disease?

         YES    NO   40. Family history of diabetes, heart problems, tumors ?            YES   NO    51. Diabetes?

         IV. Do You Have Or Have You Had:                                                                   V.  Are You Taking:

         YES   NO    52.  Tumors, cancer?                                                                        YES    NO      62.Recreational drugs? (Addiction)

         YES    NO   53. Radiation treatments?                                                                  YES    NO     63.  Tobacco in any  form?   

        YES   NO     54. Quemotherapy                                                                         YES    NO       64. Alcohol?

          YES   NO   55.  Prosthetic heart valve?                                                               YES   NO      65.  Drug, medicines, (including Aspirin,Phen-Phen) ?

          YES   NO    56.   Artificial joint?                                                                              Please list______________________________

          YES   NO    57.  Contact   lenses?                                                                          YES    NO   66. Are you taking any Phen-fen, Bisphosphates (Fosamax,

         YES    NO    58. Blood transfusions?                                                                                              Actonel, Bonivia..)?

          YES   NO    59. Surgeries?                                                                                    VI.  Women Only:

          YES    NO   60. Pacemakers?                                                                              YES    NO    67.   Are you or could you be pregnant or nursing?

          YES    NO   61. Psichiatric Care?                                                                         YES    NO     68.   Taking birth control pills ?

                                  VII. All Patients:

           YES     NO           69.  Do you  have  had any other diseases or medical problems  NOT listed on this form?

            Please explain__________________________________________________________________________

         To the  best of my knowledge,  I  have answered every  question completely and accurately.  I  will inform  Dr. Ingrid Mack  of any change in

          my health  and or  medication.

          Date____/____/_____ Patient’s Signature_________________________Doctor_______________________