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713-909-7050

Medical HistoryDr. Sabbahi2019-06-27T20:39:49+00:00

Medical History

Patient Name*
First Last
Birth Date*
Date Format: MM slash DD slash YYYY
Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Heath problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions.
Are you under a physicians care now?*
- Yes
- No
If Yes:
Have you ever been hospitalized or had a major operation?*
- Yes
- No
If Yes:
Have you ever had a serious head or neck injury?*
- Yes
- No
If Yes:
Are you taking any medications pills or drugs?*
- Yes
- No
If Yes:
Do you take, or have you taken, Fhen-Fen or Redux?*
- Yes
- No
If Yes:
Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates?*
- Yes
- No
If Yes:
Are you on a special diet?*
- Yes
- No
If Yes:
Do you use tobacco?*
- Yes
- No
Do you use controlled substances?*
- Yes
- No
Sex:*
Women: Are you
- Pregnant/Trying to get pregnant?
- Nursing?
- Taking oral contraceptives?
Are you allergic to any of the following?
- Asprin
- Penicillin
- Codeine
- Acrylic
- Metal
- Latex
- Local Anesthetics
- Other
If other, please explain.
Do you have, or have you had, any of the following?
AIDS/HIV Positive*
- Yes
- No
Cortisone Medicine*
- Yes
- No
Hemophilia*
- Yes
- No
Renal Dialysis*
- Yes
- No
Alzheimer's Disease*
- Yes
- No
Diabetes*
- Yes
- No
Hepatitis A*
- Yes
- No
Rheumatic Fever*
- Yes
- No
Anaphylaxis*
- Yes
- No
Drug Addiction*
- Yes
- No
Hepatitis B or C*
- Yes
- No
Rheumatism*
- Yes
- No
Anemia*
- Yes
- No
Easily Winded*
- Yes
- No
Herpes*
- Yes
- No
Scarlet Fever*
- Yes
- No
Angina*
- Yes
- No
Emphysema*
- Yes
- No
High Blood Pressure*
- Yes
- No
Shingles*
- Yes
- No
Arthritis/Gout*
- Yes
- No
Epilepsy or Seizures*
- Yes
- No
Hives or Rash*
- Yes
- No
Sickle Cell Disease*
- Yes
- No
Sickle Cell Disease*
- Yes
- No
Artificial Heart Valve*
- Yes
- No
Excessive Bleeding*
- Yes
- No
Hypoglycemia*
- Yes
- No
Sinus Trouble*
- Yes
- No
Artificial Joint*
- Yes
- No
Excessive Thirst*
- Yes
- No
Irregular Heartbeat*
- Yes
- No
Spina Bifida*
- Yes
- No
Asthma*
- Yes
- No
Fainting Spells/Dizziness*
- Yes
- No
Kidney Problems*
- Yes
- No
Stomach/Intestinal Disease*
- Yes
- No
Blood Disease*
- Yes
- No
Frequent Cough*
- Yes
- No
Leukemia*
- Yes
- No
Stroke*
- Yes
- No
Blood Transfusion*
- Yes
- No
Frequent Diarrhea*
- Yes
- No
Liver Disease*
- Yes
- No
Swelling of Limbs*
- Yes
- No
Breathing Problem*
- Yes
- No
Frequent Headaches*
- Yes
- No
Low Blood Pressure*
- Yes
- No
Thyroid Disease*
- Yes
- No
Bruise Easily*
- Yes
- No
Genital Herpes*
- Yes
- No
Lung Disease*
- Yes
- No
Tonsilitis*
- Yes
- No
Cancer*
- Yes
- No
Glaucoma*
- Yes
- No
Mitral Valve Prolapse*
- Yes
- No
Tuberculosis*
- Yes
- No
Chemotherapy*
- Yes
- No
Hay Fever*
- Yes
- No
Pain in Jaw Joints*
- Yes
- No
Tumors or Growths*
- Yes
- No
Chest Pains*
- Yes
- No
Heart Attack/Failure*
- Yes
- No
Parathyroid Disease*
- Yes
- No
Ulcers*
- Yes
- No
Cold Sores/Fever Blisters*
- Yes
- No
Heart Murmur*
- Yes
- No
Psychiatric Care*
- Yes
- No
Venereal Disease*
- Yes
- No
Congenital Heart Disorder*
- Yes
- No
Heart Pace Maker*
- Yes
- No
Radiation Treatments*
- Yes
- No
Yellow Jaundice*
- Yes
- No
Convulsions*
- Yes
- No
Heart Trouble/Disease*
- Yes
- No
Recent Weight Loss*
- Yes
- No
Have you every had any serious illness not listed above?*
- Yes
- No
If yes, please explain
Comments
To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health, It is my responsibility to inform the dental office of any changes in medical status.
SIGNATURE OF PATIENT, PARENT, OR GUARDIAN*
Date*
Date Format: MM slash DD slash YYYY

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Fax: 713-574-2775
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