THE PRACTICE | BEVERLY HILLS BOUTIQUE DENTAL
| MEDICAL HISTORY | |||||||||||
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| DO YOU HAVE or HAVE YOU EVER HAD (check all that apply): | |
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1.
Hospitalization for illness or injury
………
2.
An allergic or bad reaction to any of the following:
3.
Heart problems, or cardiac stent within the last 6 months…………….…………………
4.
History of infective endocarditis………………………………………….……………………………….……………………………
5.
Artificial heart valve, repaired heart defect (PFO)…………………………………….…………….…………………
6.
Pacemaker or implantable defibrillator……………………….……………………………………
7.
Orthopedic implant (joint replacement)……………..……………………………………………
8.
Rheumatic or scarlet fever…………………………………….…………………………………………
9.
High blood pressure…………………………………………………………………………………………
10.
A stroke (taking blood thinners)………………………………………………………………………
11.
Anemia or other blood disorder………………………………………………………………………
12.
Prolonged bleeding due to a slight cut (INR > 3.5)……………………………………………
13.
COVID-19, Pneumonia, emphysema, shortness of breath, sarcoidosis………….…
14.
Chronic ear infections, tuberculosis, measles, chicken pox………………………………
15.
Asthma………………………………………………………………………………………..……………….
16.
Breathing or sleep problems (e.g. sleep apnea, snoring,
sinus)……………………….
17.
Kidney disease………………………………………………………………….…………………………….
18.
Liver Disease or Jaundice…………………………………………………………......……………….
19.
Vertigo (e.g. ”the room is spinning”)……….....…………………………....…………………..
20.
Thyroid, parathyroid disease, or calcium deficiency…………………………………....…
21.
Hormone deficiency or imbalance
..……
22.
High cholesterol or taking statin drugs………………………………………………..………….
23.
Diabetes (HbA1c =
)…………………………………
24.
Stomach or duodenal ulcer…………………………………………………….………………………
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25.
Digestive or eating disorders (e.g. celiac disease, gastric
reflux, bulimia, anorexia)
…..………
26.
Osteoporosis/osteopenia (i.e. taking bisphosphonates)……………………………..…..
27.
Arthritis……………………………………………………………………..……………………………………
28.
Autoimmune disease (e.g. rheumatoid arthritis, lupus,
scleroderma)…………………………………………………………………………………………………
29.
Glaucoma………………………………………………………………………………………………………..
30.
Contact lenses…………………………………………………………………………………………………
31.
Head or neck injuries
…………..……
32.
Epilepsy, convulsions (seizures)……………………………………………………………………….
33.
Neurologic disorders (e.g. ADD/ADHD, prion disease)………………….………………….
34.
Viral infections and cold sores……………………………………………………………………...…
35.
Any lumps or swelling in the mouth…………………………………………………...…………..
36.
Hives, skin rash, hay fever……………………………………………………………………………….
37.
Sexually transmitted illness, HPV…………………………………………………………………….
38.
Hepatitis (type
)………………………………………………………………
39.
HIV/AIDS…………………………………………………………………..…………………………………….
40.
Cancer, Tumor, abnormal growth
…..……
41.
Radiation therapy………………………………………………………..………………………………….
42.
Chemotherapy, immunosuppressive medication…………………………………………….
43.
Emotional difficulties…………………………………………………………………...…………………
44.
Psychiatric treatment………………………………………………………………………………………
45.
Antidepressant medication……………………………………………………………………………..
46.
Alcohol/recreational drug use………………………………………………………..……………….
ARE YOU:
47.
Presently being treated for any other illness
……
48.
Aware of a change in your health in the last 24 hours (e.g.
fever, chills, new cough, or diarrhea)
……………
49.
Taking medication for weight management……………………………………………..…….
50.
Taking dietary supplements…………………………………………………………..……………….
51.
Often exhausted or fatigued…………………………………………………………………………..
52.
Experiencing frequent headaches…………………………………..………………………………
53.
A smoker, smoked previously or use smokeless tobacco…………………………………
54.
Considered a touchy/sensitive person…………………………….……………………………..
55.
Often unhappy or depressed……………………………………………………...........………….
56.
Taking birth control pills…………………………………………..…………………………………….
57.
Currently pregnant……………………………………………………..………………………………….
58.
Diagnosed with a prostate disorder…………………………………..……………………………
|
| DO YOU HAVE or HAVE YOU EVER HAD (check all that apply): |
|---|
|
1.
Hospitalization for illness or injury
.……………………………………
2.
An allergic or bad reaction to any of the following:
3.
Heart problems, or cardiac stent within the last 6 months…………….……………………………………………………………………
4.
History of infective endocarditis…………………………………………………………………………………………….……………………………
5.
Artificial heart valve, repaired heart defect (PFO)………………………….……………………………………………………………………
6.
Pacemaker or implantable defibrillator……………………….………………………………………………………………………………………
7.
Orthopedic implant (joint replacement)……………..………………………………………………………………………………………………
8.
Rheumatic or scarlet fever…………………………………….……………………………………………………………………………………………
9.
High blood pressure…………………………………………………………………………………………………………………………………
10.
A stroke (taking blood thinners)…………………………………………………………………………………………………………………………
11.
Anemia or other blood disorder…………………………………………………………………………………………………………………………
12.
Prolonged bleeding due to a slight cut (INR > 3.5)………………………………………………………………………………………………
13.
COVID-19, Pneumonia, emphysema, shortness of breath, sarcoidosis…………………………………………………………………………..……
14.
Chronic ear infections, tuberculosis, measles, chicken pox…………………………………………………………………………………
15.
Asthma……………………………………………………………………………………………………………………………………………..……………….
16.
Breathing or sleep problems (e.g. sleep apnea, snoring,
sinus)………………………………………………………………………….
17.
Kidney disease………………………………………………………………….…………………………….
18.
Liver Disease or Jaundice………………………………………………………………………………………………………....……………….
19.
Vertigo (e.g. ”the room is spinning”)………………………………………………………………………....……………………………..
20.
Thyroid, parathyroid disease, or calcium deficiency……………………………………………………………………………………....…
21.
Hormone deficiency or imbalance
………………………………
22.
High cholesterol or taking statin drugs…………………………………………………………………………………………………..………….
23.
Diabetes (HbA1c =
)……………………………………………………………………
24.
Stomach or duodenal ulcer……………………………………………………………………………………………………….………………………
|
|
25.
Digestive or eating disorders (e.g. celiac disease, gastric reflux, bulimia, anorexia)
…
26.
Osteoporosis/osteopenia (i.e. taking bisphosphonates)……………………………………………………………………..………..…..
27.
Arthritis……………………………………………………………………..……………………………………………………..………………………………
28.
Autoimmune disease (e.g. rheumatoid arthritis, lupus, scleroderma)………………………………..……………………..………
29.
Glaucoma……………………………………………………………………………………………………………………..…………………………………..
30.
Contact lenses…………………………………………………………………………………………………..………………………………………………
31.
Head or neck injuries
…………………………………
32.
Epilepsy, convulsions (seizures)………………………………………………………………………………..……………………………………….
33.
Neurologic disorders (e.g. ADD/ADHD, prion disease)…………………………………………………………………...………………….
34.
Viral infections and cold sores………………………………………………………………..……………………………………………………...…
35.
Any lumps or swelling in the mouth……………………………………………………………………..……………………………...…………..
36.
Hives, skin rash, hay fever…………………………………………………………………………..…………………………………………………….
37.
Sexually transmitted illness, HPV………………………………………………………………………..…………………………………………….
38.
Hepatitis (type
)………………………………………………………………………………….
39.
HIV/AIDS…………………………………………………………………………………………………..………………..…………………………………….
40.
Cancer, Tumor, abnormal growth
……………………………
41.
Radiation therapy……………………………………………………………………………..…………………………..………………………………….
42.
Chemotherapy, immunosuppressive medication………………………………………………………………..…………………………….
43.
Emotional difficulties………………………………………………………………………..…………………………………………...…………………
44.
Psychiatric treatment………………………………………………………………………………..………………………………………………………
45.
Antidepressant medication……………………………………………………………………………..………………………………………………..
46.
Alcohol/recreational drug use…………………………………………………………………………..……………………………..……………….
ARE YOU:
47.
Presently being treated for any other illness
………………………
48.
Aware of a change in your health in the last 24 hours (e.g. fever, chills, new cough, or diarrhea)
49.
Taking medication for weight management………………………………………………………………………..……………………..…….
50.
Taking dietary supplements…………………………………………………………………………..………………………………..……………….
51.
Often exhausted or fatigued……………………………………………………………………………..……………………………………………..
52.
Experiencing frequent headaches………………………………………………………………………..…………..………………………………
53.
A smoker, smoked previously or use smokeless tobacco…………………………………………………………..………………………
54.
Considered a touchy/sensitive person…………………………….…………………………………………………..…………………………..
55.
Often unhappy or depressed………………………………………………………………………..……………………………...........………….
56.
Taking birth control pills…………………………………………..………………………………………………………………..…………………….
57.
Currently pregnant……………………………………………………..…………………………………………………………………..……………….
58.
Diagnosed with a prostate disorder…………………………………..…………………………………………………………..…………………
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Describe any current medical treatment, impending surgery, genetic/development delay, or other treatment that may possibly affect your dental treatment (e.g. Botox, collagen injections)
| LIST ALL MEDICATIONS, SUPPLEMENTS, AND OR VITAMINS TAKEN WITHIN THE LAST 2 YEARS |
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Drug
1.
2.
3.
4.
Purpose
Drug
5.
6.
7.
8.
Purpose
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If there is another individual that should be consulted regarding treatment decisions, please provide their information below:
The practice of dentistry involves treating the whole person. If the dentist determines that there may be a potentially medically-compromised situation, medical consultation may be needed prior to commencement of dental treatment. I authorize the dentist to contact my physician.
I certify that I have read and understand this form. To the best of my knowledge, I have answered every question completely and accurately. I will inform my dentist of any change in my health and/or medication. Further, I will not hold my dentist, or any other member of his/her staff, responsible for any errors or omissions that I may have made in the completion of this form.
Reservation Policy: Each appointment is a reservation with one of our Doctors or Hygienists and we strive to be punctual because we value our patients’ time. We ask for a minimum of 48 hours notice to cancel or reschedule any reservations and to avoid a Missed Reservation Fee. For appointments over 2 hours long or scheduled outside of our normal business hours, we request a 25% non-refundable deposit to secure your reservation.
PATIENT’S SIGNATURE