Form: Eaglesoft Medical History 2023

Patient Information

Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health 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.
Do you have a Primary Care Physician? If yes, please provide the name, phone number and location of your doctor.
Are you taking any medications including supplements? If yes, please list all medications.
Have you been hospitalized or had a major operation in the last 5 years?
Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates?
Do you use any tobacco products including chewing tobacco or vaping products?
Do you currently use any controlled substances?
Have you ever been treated for cancer?
Do you have a fever, dry cough or any symptoms of a respiratory illness?
Do you need to take a pre-med for a dental visit?

Women: Are you...

Are you allergic to any of the following?

Do you have or have you had any of the following?

Heart Attack/Failure
Angina/Chest Pain
Easily Winded
Heart Murmur
Mitral Valve Prolapse
Congenital Heart Disease
Irregular Heart Beat
Swelling of Limbs
High Blood Pressure
Heart Pacemker
Stents
Type I Diabetes
Type II Diabetes
Excessive Thirst
Renal Dialysis
Hypoglycemia
Kidney Problems
IBS
Frequent Diarrhea
Gastric Refux
Ulcers
Liver Disease
Yellow Jaundice
Asthma
Emphysema
Frequent Cough
COPD
Breathing Problems
Lung Disease
Sore Throat
Glaucoma
Anemia
Bruise Easily
Hemophilia
Sickle Cell Disease
Blood Transfusion
Thyroid Disease
Parathyroid Disease
Recent Weight Loss
Cortisone Medication
Hives/Rash
Arthritis
Artificial Joint
Rheumatoid Arthritis
Osteoporosis
Multiple Sclerosis
ALS/Lou Gehrig's Disease
Parkinson's Disease
Stroke/TIA
Epilepsy/Siezure
Fainting/Dizziness
Tuberculosis
Scarlet Fever
Hepatitis A
Hepatitis B or C
AIDS/HIV Positive
STD
Frequent Canker Sores
Cold Sores
Shingles
Lyme Disease
Psyciatric Care
ADHA/ADD
Drug Addiction
Alzheimer's Disease
Dementia
PTSD
High Cholesterol
Autism Spectrum Disorder
Sleep Apnea
Anxiety/Depression
Please list any conditions you have not listed above.

Patient, Parent or Guardian

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.

Sign Form

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.