ORAL SEDATION MEDICAL HISTORY
Patient’s name:________________________________________________________Date__________________________
Address:______________________________________________________________________________________________
Physician’s Name & Address ___________________________________________________Phone Number_____________
Approximate date of last examination_______________________Patient’s Height_____________Weight______________
1.
Are you currently under medical treatment? Yes____ No____ If yes, please
explain________________________________________________________________________
2. Do you have or have you ever had any of the following? (circle Y for Yes or N for No)
a.
A heart ailment/prosthetic
heart valve
b. High/low blood pressure
c. Any lung disease
d. Diabetes
e. Scarlet/rheumatic fever
f. Rheumatism or arthritis
g. Any blood disease
h. Any liver disease or hepatitis
i. Any kidney disease
j Stomach or intestinal
disease
Y - N
Y
Y
Y
Y
Y
Y
Y
Y
Y
-
N
N
N
N
N
N
N
N
N
k.
Shortness of breath with
limited activity
l. Chest pain or angina pectoris
m. Asthma
n. Stroke
o. Sinus problems
p. Alcohol or drug dependency
q. Artificial joints
r. Blood transfusion
s. ADD or ADHD
t. Hemophilia
u. AIDS or HIV
Y - N
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
-
N
N
N
N
N
N
N
N
N
N
v.
w.
x.
y.
z.
aa.
bb.
cc.
dd.
ee.
Cold sores or fever blisters
History of Fen-Phen or
Redux
Emphysema
Heart murmur
Tumors or growths
Pacemaker
Heart attacks
Panic attacks
Prolonged bleeding
following injury or surgery
Low bone density/
Osteoporosis medications
Y - N
Y - N
Y
Y
Y
Y
Y
Y
-
N
N
N
N
N
N
Y - N
Y - N
3.Is there anything of importance in your medical history that has not been asked?_______________________________________
4.Are you allergic to any known materials?_________________________Latex Allergy?__________________
5. Have you had any adverse response to drugs such as Penicillin, Aspirin. Codeine?_____________________________________
6. Are you now taking any drugs or medicines? If so, please list_______________________________________________________
7. Are you now on any special kind of diet?_______________________________________________________________________
8. Do you have a history of fainting or convulsions?______________________________________________________________
9. Radiation treatments or chemotherapy?_____________________________________________________
10. Is there anything of importance in your medical history that has not been asked?_________If yes, please explain___________
________________________________________________________________________________________________________
For Women Only:
a. Are you now pregnant? If so, when are you due?________________________________________________________________
b. Are you taking birth control pills? ___________________________________________________________________________
c. I understand I should consult my pharmacist if I ever take antibiotics, concerning their effect on birth control. Initials__________
I have read and completed the medical history and I authorize the release of my dental records from my previous dentists, and any
future dentists.
Patient’s/Parent’s signature: ____________________________________________________ Date:_________________________
Staff signature: _______________________________________________________ Date: _________________________________
Oral sedation medical history 6/10