Eaglesoft Medical History

Patient Name:

Birth Date:

Date Created:

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
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, Phen-Fen or Redux?
Yes
No
If yes,
Have you ever taken Fosamax, Boniva, Actonel, or any other medications containg bisphosphonates?
If yes,
Are you on a special diet? Yes No
If yes,
Do you use tobacco? Yes No
If yes,
Women: Are you..
Pregnant/Trying to get pregnant

Nursing?

Yes

No

Taking oral contraceptives?

Are you allergic to any of the following?

Aspirin
Penicillin
Codeine
Acrylic
Metal Latex
Sulfa Drugs
Local Anesthetics
Other?
Do you use controlled substances?
If yes,

If yes,

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

AIDS/HIV Positive
Alzheimers Disease
Anaphylaxis
Anemia
Angina
Arthritis/Gout
Artificial Heart Valve
Artificial Joint
Asthma
Blood Disease
Blood Transfusion
Breathing Problems
Bruise Easily
Cancer
Chemotherapy
Chest Pains
Cold Sore/Fever Blister

Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes

Yes
Congenital Heart Disorder
Yes
Convulsions
Yes

No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No

Cortisone Medicine
Yes
Diabetes
Yes
Drug Addiction
Yes
Easily Winded
Yes
Emphysema
Yes
Epilepsy or Seizures
Yes
Excessive Bleeding
Yes
Excessive Thirst
Yes
Fainting Spells/Dizziness
Yes
Frequent Cough
Yes
Frequent Diarrhea
Yes
Frequent Headaches
Yes
Genital Herpes
Yes
Glaucoma
Yes
Hay Fever
Yes
Heart attack/Failure
Yes
No Heart Murmur
Yes
Heart Pacemaker
Yes
No Heart Trouble
Yes
No

No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No

Hemophilia
Hepatitis A
Hepatitis B or C
Herpes
High Blood Pressure
High Cholesterol
Hives or Rash
Hypoglycemia
Irregular Heartbeat
Kidney Problems
Leukemia
Liver Disease
Low Blood Pressure
Lung Disease
Mitral Valve Prolapse
Osteoporosis
Pain in Jaw Joints
Parathyroid Disease
Psychiatric Care

Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes

No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No

Radiation Treatments Yes No

Recent Weight Loss
Yes No
Renal Dialysis
Yes No
Rheumatic Fever
Yes No
Rheumatism
Yes No
Scarlet Fever
Yes No
Shingles
Yes No
Sickle Cell Disease
Yes No
Sinus Trouble
Yes No
Spina Bifida
Yes No
Stomach/Intestinal
Yes No
Stroke
Yes No
Swelling of Limbs
Yes No
Thyroid Disease
Yes No
Tonsillitis
Yes No
Tuberculosis
Yes No
Tumors or Growths
Yes No
Ulcers
Yes No
Venereal Disease
Yes No
Yellow Jaundice
Yes No

8/12/15

Have you ever had any serious illness not listed?

Yes

No

If yes,

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 patients) health. It is my responsibility to inform the dental office of any changes in medical
status.
Signature of Parent or Guardian: ___________________________________ Date:

Family History

Alcoholism
Asthma,
Lung
Disease
Bleeding
Disorders
Cancer
Diabetes
(specify
type)
Epilepsy,
seizure
disorder
Glaucoma
Heart
Disease
High Blood
Pressure
Kidney
Disease
Mental
illness,
depression,
anxiety,
ADHD, etc.
Migraines
Osteoporosi
s
Stroke
Thyroid
Disease
Other
(specify)

Siblings

Mother

Father

Mothers
Parents

Fathers
Parents

Please list any other information that you feel is pertinent to your childs medical care:
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