Dr.Jared Kenwood

MEDICAL HISTORY

PATIENT NAME Birth Date 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.

  • Are you under a physician's care now?

    yes   No

    If yes, please explain:

  • Have you ever been hospitalized or had a major operation?

    yes   No

    If yes, please explain:

  • Have you ever had a serious head or neck injury?

    yes   No

    If yes, please explain:

  • Are you taking any medications, pills, or drugs?

    yes   No

    If yes, please list:

  • Do you take, or have you taken, Phen-Fen or Redux?

    yes   No

  • Are you on a special diet?

    yes   No

  • Do you use tobacco?

    yes   No

  • Do you use controlled substances?

    yes   No

  • Do you need to pre-medicate?

    yes   No

    If yes, please explain:

  • Are you Pregnant/Trying to get pregnant?

    yes   No

  • Taking oral contraceptives?

    yes   No

  • Nursing?

    yes   No
    • Are you allergic to any of the following?
  • Aspirin
  • Penicillin
  • Codeine
  • Metal
  • Latex
  • Acrylic
  • Local Anesthetics
  • Other Allergies?
  • If yes, 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
  • 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
  • Tonsillitis
    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 ever had any serious illness not listed above?

    yes   No

    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