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Menu
About
Our Team
Our Lab
Our Implants
Same-Day Dental Implants
Same-Day Dentures
All On 4 Implants
Snap-On Dentures
Single Tooth Dental Implant
Before & After Gallery
What To Expect
Resources
Before & After Gallery
Same Day vs Traditional Implants
New Patients
Finance & Insurance
Warranty Policy
FAQs
Blog
Implant Glossary
Contact Us
Medical History Form
Preferred Name:
Mr.
Dr.
Miss
Mr.
Mrs.
Ms.
Prof.
Rev.
Prefix
First
Middle
Last
Gender
Male
Female
Prefer not to disclose
Birth Date:
DD slash MM slash YYYY
Do you or have you had any of the following conditions? Check all that apply.
Heart Attack
Heart Attack
When?
Stroke/TIA
Stroke/TIA
When?
Angina/Chest Pain/Shortness of Breath
Angina/Chest Pain/Shortness of Breath
Atrial Fibrillation
Atrial Fibrillation
Heart Arrhythmia/Irregular Heartbeat
Heart Arrhythmia/Irregular Heartbeat
Congenital Heart Disease
Congenital Heart Disease
Heart Valve Replacement/Repair
Heart Valve Replacement/Repair
Type?
When?
Pacemaker
Pacemaker
Low Blood Pressure
Low Blood Pressure
High Blood Pressure
High Blood Pressure
Vertigo
Vertigo
Faint/Dizzy Spells/Light-headedness
Faint/Dizzy Spells/Light-headedness
COPD
COPD
Asthma
Asthma
Sleep Apnea
Sleep Apnea
C-Pap Machine
C-Pap Machine
Cancer
Cancer
Type?
When?
Cancer
Radiation
Chemotherapy
Surgery
Active Treatment
Remission
Remission Since?
Diabetes
Diabetes
IDDM (Insulin Dependent)
IDDM (Insulin Dependent)
NIDDM (Non-Insulin Dependent)
NIDDM (Non-Insulin Dependent)
Average blood sugar range:
Malignant Hyperthermia
Malignant Hyperthermia
Drug/Alcohol Dependence
Drug/Alcohol Dependence
Past
Past
Current
Current
Steroid Therapy
Steroid Therapy
Steroid Therapy Details
Heartburn/Gastric Reflux
Heartburn/Gastric Reflux
Kidney Disease
Kidney Disease
Liver Disease
Liver Disease
Stomach Ulcers
Stomach Ulcers
HIV/AIDS
HIV/AIDS
Hepatitis
Hepatitis
A
A
B
B
C
C
Autoimmune Disorder
Autoimmune Disorder
Multiple Sclerosis
Multiple Sclerosis
Lupus
Lupus
Rheumatoid Arthritis
Rheumatoid Arthritis
Other
Other
Steroid Therapy Details
Thyroid Disease
Thyroid Disease
Hypo Thyroid
Hypo Thyroid
Hyperthyroid
Hyperthyroid
Chronic Neck/Back Pain
Chronic Neck/Back Pain
Osteoporosis
Osteoporosis
Seizures/Epilepsy
Seizures/Epilepsy
Date of last seizure
Blood Disorder
Blood Disorder
Ex: Anemia, Sickle Cell
ADD/ADHD
ADD/ADHD
Dementia
Dementia
Developmental Delay
Developmental Delay
Developmental Delay Details
Autism Spectrum Disorder
Autism Spectrum Disorder
Non-Verbal
Non-Verbal
Depression/Anxiety
Depression/Anxiety
Psychiatric Disorder
Psychiatric Disorder
Psychiatric Disorder Details
Hearing Difficulty/Impairment
Hearing Difficulty/Impairment
Hearing Difficulty/Impairment Details
Glaucoma
Glaucoma
Closed/Narrow
Closed/Narrow
Open/Wide
Open/Wide
Glasses
Glasses
Contact Lenses
Contact Lenses
Visually Impaired
Visually Impaired
Requires Wheelchair Access
Requires Wheelchair Access
Can transfer alone or with help
Can transfer alone or with help
Cannot Transfer
Cannot Transfer
Have you had any surgeries, major illnesses or hospitalizations?
Yes
No
Please list
Are you currently (or within the past 5 years) being treated for any medical conditions or disease not listed above?
Yes
No
Please list
When was your last physician visit (approximately)?
Do you have a prosthetic or artificial joint?
Yes
No
Location
Date(s) of placement
Have you ever had an organ transplant or implanted medical devices (ex: stimulation devices, screws, pins, etc.)?
Yes
No
Location
Date(s) of placement
Do you smoke or chew tobacco products?
Yes
No
If you quit using tobacco, when?
Do you use electronic cigarettes or a vaporizer?
Yes
No
Are you pregnant?
Yes
No
Expected due date
Are you breast feeding?
Yes
No
Do you have any allergies to medications?
Yes
No
Please list, along with reactions
Do you have any other allergies?
Yes
No
Please list, along with reactions
Do you have an allergy to latex?
Yes
No
Medications
Medications list
I have attached a list of my most recent medications
Please contact my pharmacy for my most recent list.
Pharmacy Name
Location
Phone
Are you currently taking any medications?
Yes
No
(Prescriptions, patches, inhalers, vitamins, supplements, holistic or non-prescription drugs, including medical or recreational marijuana):
Please list
Do you currently take any prescription blood thinners?
Yes
No
Prescription blood thinners details
Coumadin (Warfarin)
Pradaxa (Dabigatran)
Eliquis (Apixaban)
Xarelto (Rivaroxaban
Plavix (Clopidogrel)
Other
Prescription blood thinners (other details)
Have you ever been treated for osteoporosis?
Yes
No
Please check the following medications you are currently taking or have taken
Fosamax, Fosavance (Alendronate)
Didronel (Etidronate)
Zometa, Reclast, Aclasta (Zoledronic Acid)
Actonel, Atelvia (Risedronate)
Other
osteoporosis (other details)
Medication began
Medication Discontinued
Does dentistry/dental treatment cause you anxiety?
Yes
No
Please explain
To the best of my knowledge, the above information is correct:
Patient/Parent/Guardian Signature
Patient/Parent/Guardian Signature
Name of Patient/Parent/Guardian (print)
Name of Patient/Parent/Guardian (print)
Date
MM slash DD slash YYYY
Date
Dentist Signature
Dentist Signature
Name
This field is for validation purposes and should be left unchanged.
