Medical History Update Form - Abella Dental

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300 110th Ave. NE #1-01 Bellevue, WA 98004

(425) 709-2468

Tues - Thurs 7AM -5PM

Mon & Fri: Hours Vary

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Home
Office
General
Cosmetic
Restorative
Patient Info
Contact/Pay
- Appointments
- Make A Payment

Medical History Update Form

General Information

Name *

First

Last

Date of Birth *//

Age

Healthcare Provider Information

Name of Your Medical Doctor

Medical Doctor Phone Number

Date of Last Visit

Medical Health History

Heart problems:

Yes
No

Chest pain

Yes
No

Shortness of breath

Yes
No

Blood pressure problem

Yes
No

Heart murmur

Yes
No

Heart valve problem

Yes
No

Taking heart medication

Yes
No

Rheumatic fever

Yes
No

Pacemaker

Yes
No

Artificial heart valve

Yes
No

Blood problems:

Yes
No

Easy bruising

Yes
No

Frequent nosebleeds

Yes
No

Abnormal bleeding

Yes
No

Blood disease (anemia)

Yes
No

Ever require a blood transfusion?

Yes
No

Allergy Problems:

Yes
No

Hay fever

Yes
No

Sinus problems

Yes
No

Skin rashes

Yes
No

Taking allergy medication

Yes
No

Asthma

Yes
No

Intestinal Problems:

Yes
No

Ulcers

Yes
No

Weight gain or loss

Yes
No

Special diet

Yes
No

Constipation/Diarrhea

Yes
No

Kidney or bladder problems

Yes
No

Bone or Joint Problems:

Yes
No

Arthritis

Yes
No

Back or neck pain

Yes
No

Joint replacement (e.g. total hip, pins, or implants)

Yes
No

Are you taking or have you taken Bisphosphonate (e.g., Fosamax, Boniva, Actonel, Atelvia, Reclast, etc.)

Yes
No

Fainting Spells, Seizures or Epilepsy

Yes
No

Stroke(s)

Yes
No

Frequent or severe headaches

Yes
No

Thyroid problems

Yes
No

Persistent cough or swollen glands

Yes
No

Premedications required by physician

Yes
No

Cancer/tumor

Yes
No

Diabetes

Yes
No

Urinate more than 6 times a day

Yes
No

Thirsty or mouth is dry much of the time

Yes
No

Family history of diabetes

Yes
No

Tuberculosis or other respiratory disease

Yes
No

Do you drink alcohol?

Yes
No

If so, how much?

Do you smoke?

Yes
No

If so, please describe

Hepatitis, jaundice, or liver trouble

Yes
No

Herpes or other STD

Yes
No

HIV-positive / AIDS

Yes
No

Glaucoma

Yes
No

Do you wear contact lenses?

Yes
No

History of head injury?

Yes
No

Epilepsy or other neurological disease?

Yes
No

History of alcohol or drug abuse?

Yes
No

Do you have any disease, condition, or problem not listed previously that you feel we should now about?

Yes
No

If so, please describe

Please list any recent surgeries and dates:

Are you allergic, or have you reacted adversely to any of the following?

Aspirin

Yes
No

Codeine

Yes
No

Dental Anesthetics

Yes
No

Erythromycin

Yes
No

Jewelry

Yes
No

Latex

Yes
No

Metals

Yes
No

Penicillin

Yes
No

Tetracycline

Yes
No

Sulfa

Yes
No

Other

Yes
No

Please list any medications you are currently taking:

For Women:

Are you taking birth control pills or other hormones?

Yes
No

Are you pregnant?

Yes
No

If yes, number of weeks:

Are you nursing?

Yes
No

Have you reached menopause?

Yes
No

If so, do you have any symptoms?

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300 110th Ave NE
Suite 1-01
Bellevue, WA 98004

Monday: Hours Vary
Tuesday: 7:00AM - 5:00PM
Wednesday: 7:00AM - 5:00PM
Thursday: 7:00AM - 5:00PM
Friday: Hours Vary

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