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MEDICAL HISTORY for ENDODONTIC PATIENTS (Root Canal)

ANSWER ALL QUESTIONS. CIRCLE Y (Yes) or N (No)
ARE YOU NOW UNDER THE CARE OF A PHYSICIAN? _____
Name__________________________________________________ PRESENT OR PAST CONDITION
Specialty_______________________________________________ Congestive heart failure (CHF) …………………… Y N Conditions treated________________________________________ Heart disease, arteriosclerosis …………………… Y N _______________________________________________________ Angina, chest pain …………………………………. Y N _______________________________________________________ Previous heart at ack ……………………………… Y N Recent surgery or hospital stay? ____________________________ Heart surgery ………………………………………. Y N _______________________________________________________ Congenital heart defect …………………………… Y N May we request medical information related to your treatment? ____ Heart valve replacement …………………………. Y N Pacemaker, palpitations …………………………. Y N CURRENT MEDICATIONS YOUR TAKING
High blood pressure ………………………………. Y N Antibiotics ____________________________________ Y N Low blood pressure ………………………………. Y N Pain medication________________________________ Y N Rheumatic fever, rheumatic heart problems …… Y N Oral steroids such as Prednisone__________________ Y N Heart murmur ……………………………………… Y N Aspirin therapy, Aleve, Motrin _____________________ Y N Mitral valve prolapse, other valve problems …… Y N Blood thinners _________________________________ Y N Previous stroke, CVA, or TIA ……………………. Y N Blood pressure meds____________________________ Y N Epilepsy, seizures, convulsions …………………. Y N Nitroglycerin___________________________________ Y N Fainting spells, dizzy spel s ………………………. Y N Digitalis, Inderal________________________________ Y N Joint, knee, hip replacement ……………………… Y N Cholesterol lowering ____________________________ Y N Kidney disease ……………………………………. Y N Anti-depressants/tranquilizers _____________________ Y N Hepatitis/liver disease Type A B C ……………… Y N Insulin, diabetes _______________________________ Y N Thyroid problems, high or low …………………… Y N Antihistamines ________________________________ Y N Diabetes in self, mother, father …………………. Y N Birth control pills _______________________________ Y N Anemia, iron deficiency, sickle cell ……………… Y N Asthma meds or inhalers ________________________ Y N Bleeding disorder, hemophilia, bruising ………… Y N Epilepsy/seizure meds___________________________ Y N Leukemia or other cancer ………………………… Y N Thyroid meds _________________________________ Y N Chemotherapy, radiation therapy ………………. Y N Fosamax, Actonel, Boniva or other osteoporosis meds … Y N HIV, AIDS …………………………………………. Y N Zometa, Reclast, Aredia, Prolia or other IV cancer meds Y N STD (sexually transmit ed disease) ……………. Y N Other meds or herbal remedies ……………………………. Y N Alcohol dependency ………………………………. Y N ___________________________________________________ Prescription drug dependency …………………… Y N Tuberculosis ………………………………………. Y N HAVE YOU HAD AN ADVERSE REACTION TO:
Tobacco use of any kind …………………………. Y N Dental anesthetic (Novocain) ………………………………. Y N Asthma, bronchitis, chronic cough ……………… Y N Latex or Rubber ……………………………………………… Y N COPD, breathing prob, emphysema, pneumonia Y N Aspirin or Ibuprophen ………………………………………… Y N Hay fever, seasonal allergy ………………………. Y N Penicil in, Cephalosporin, or other antibiotic ……………… Y N Sinus or nasal problems …………………………. Y N Codeine, Vicodin (Hydrocodone)…………………………… Y N Al ergies, rash, hives, throat swel ing …………… Y N Sedatives, tranquilizers, barbiturates ………………………. Y N Arthritis or inflammatory rheumatism …………… Y N Sulfa drugs …………………………………………………… Y N Stomach ulcers, colitis, IBS ……………………… Y N Iodine, metals, chemicals …………………………………. Y N Mouth ulcers ……………………………………… Y N Foods …………………………………………………………. Y N Glaucoma, eye diseases ………………………… Y N Other drug reactions ___________________________________ Jaw surgery ………………………………………. Y N Neuralgia, neuritis in head/neck ………………… Y N DO YOU PREFER NITROUS OXIDE/OXYGEN (laughing gas) FOR
Osteoporosis, osteopenia ………………………. Y N TREATMENT? ____Yes ____No (There is a fee for this service)
Depressed immune system ……………………. Y N Women: Are you pregnant? Nursing? ………… Y N
HAVE YOU USED THE FOLLOWING IN PAST 48 HOURS?
NAME ____________________ _____ _______________________
Cocaine ……………………………………………. Y N Date of Birth _____ /____ / ________ ___Male ___Female
Amphetamines, diet pil s ………………………… Y N Ecstasy, Methamphetamines …………………… Y N Referred By Dr.__________________________________________
Herbal remedies or herbal stimulants …………. Y N ______________________________________ ________________
Energy boosters containing ephedrine …………. Y N Patient Signature
Alcohol, tranquilizers, sedatives …………………. Y N (Guardian/parent sign for patient under 18) OTHER MEDICAL CONDITIONS NOT LISTED ABOVE:
For Of ice Use:
______________________________________________ Reviewed by __________________________ Date____________ ______________________________________________ Updated by____________________________ Date____________

Source: http://www.greaterhoustondental.com/pdfs/endo-health-history.pdf

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