Medical History Form

To help us provide safe and effective care, please complete this medical history form as accurately as possible.

Personal Medical History

Please note, all fields are required for better evaluation.

Full Name:

Date of birth:

Today's Date:

Have you received treatment for any TMJ, head, or neck symptoms?*

When was your last dental visit?

YesNo

Have you been told that you have periodontal (gum) disease?*

Do you have any existing problems with your teeth? Describe

YesNo

Is any dental treatment planned?*

Current weight:

YesNo

In the past year have you experienced any of the following:

General

Change in appetite

Fever

YesNo

YesNo

Marked Weight Change

Night Sweats

YesNo

YesNo

Recent Trauma or Injury

Unusual Weakness

YesNo

YesNo

Chronic Fatigue

Hepatitis

YesNo

YesNo

Tumors/cancer

HIV/AIDS

YesNo

YesNo

Other:

Allergies

Dairy

Dust

YesNo

YesNo

Hay Fever

Latex

YesNo

YesNo

Penicillin

Sulfa drugs

YesNo

YesNo

Wheat

Other:

YesNo

Neurological

Confusion

Dizziness

YesNo

YesNo

Fainting

Parkinson's Disease (ALS)

YesNo

YesNo

Seizures

Stroke

YesNo

YesNo

Tingling/Numbness

Tremor

YesNo

YesNo

Alzheimer's Disease

Multiple Sclerosis (MS)

YesNo

YesNo

Other:

Skin

Acne

Frequent bleeding

YesNo

YesNo

Bruising

Eczema

YesNo

YesNo

Itch

Lesions

YesNo

YesNo

Psoriasis

Other:

YesNo

Endocrine

Diabetes

Gout

YesNo

YesNo

Hormonal Changes

Thyroid problems

YesNo

YesNo

Other:

Eyes, Ears, Nose and Throat

Change in smell

Dysphagia (difficulty swallowing)

YesNo

YesNo

Ear Pain

Glaucoma

YesNo

YesNo

Hearing Loss

Visual changes

YesNo

YesNo

Nasal Obstruction

Nose Bleeding

YesNo

YesNo

Hoarseness

Sinus Problems

YesNo

YesNo

Tinnitus (ringing in ears)

Other:

YesNo

Cardiovascular

Coronary Artery Disease

Chest pain

YesNo

YesNo

Congestive Heart Failure

Heart Attack

YesNo

YesNo

Heart Murmur

High Blood Pressure

YesNo

YesNo

High Cholesterol

Irregular Heart Beat

YesNo

YesNo

Atrial Fibrillation

Other:

YesNo

Respiratory

Asthma

Bronchitis

YesNo

YesNo

Chest pressure

Congestion

YesNo

YesNo

Cough

Emphysema

YesNo

YesNo

Pneumonia

Pulmonary embolism

YesNo

YesNo

Shortness of breath

Tuberculosis

YesNo

YesNo

Other:

Gastrointestinal

Black or bloody stool

Constipation

YesNo

YesNo

Diarrhea

Reflux/GERD

YesNo

YesNo

Irritable Bowel Syndrome

Stomach pain

YesNo

YesNo

Ulcers

Vomiting

YesNo

YesNo

Other:

Genitourinary

Frequent Urination

Hematuria (blood in urine)

YesNo

YesNo

Incontinence

Kidney Stones

YesNo

YesNo

Kidney Disease

Prostate problems

YesNo

YesNo

Cervical/Uterine/Ovarian/Breast Cancer

Currently pregnant

YesNo

YesNo

Other:

MENTAL HEALTH

ADD/ADHD

Anxiety

YesNo

YesNo

Autism

Depression

YesNo

YesNo

Disorientation

Excess Stress

YesNo

YesNo

Hallucination

Memory problems

YesNo

YesNo

Eating Disorders

Chemical Dependency

YesNo

YesNo

Bipolar Disorder

Other:

YesNo

Musculoskeletal

Back pain

Fibromyalgia

YesNo

YesNo

Joint pain

Limited range of motion

YesNo

YesNo

Muscle Atrophy

Muscle pain

YesNo

YesNo

Other:

Other Medical History:

Do you smoke?*

YesNo

If yes, how many packs a day?

Do you consume alcoholic beverages?*

YesNo

If yes, how many drinks per day/week/month

List any medications you are taking and dosage:*

List any vitamins/supplements you are taking:

List any surgeries you have had:

I certify that the above information is correct to the best of my knowledge*

Records Release

I hereby authorize the Snoring and Sleep Apnea Dental Treatment Center to release my information, including diagnosis and records of treatment, concerning my past medical history to my referring physician/dentist or other health care providers, insurance company and immediate family.

I agree to the release of records

Signature:

Date:

Thank you. Your medical history has been submitted successfully.

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