Comprehensive Endodontic Medical History Form

Patient Information

• Full Name: _________________ Date: _________________
• Date of Birth: ______________ Age: __________________
• Gender: __________________ Phone: _________________
• Emergency Contact: _________ Phone: _________________

Medical History

Current Health Status

• Are you currently under medical care? □ Yes □ No
• Primary Care Physician: _______________________________
• Last medical examination date: _________________________

Medical Conditions (Check all that apply)

□ Heart Disease/Murmur □ High Blood Pressure □ Diabetes (Type: ___) □ Bleeding Disorders □ Respiratory Disease □ Autoimmune Conditions □ Cancer/Chemotherapy □ Osteoporosis □ Artificial Joints/Implants

Medications

• Current medications: _________________________________
• Anticoagulants/Blood thinners: □ Yes □ No
• Bisphosphonates: □ Yes □ No

Allergies

□ Local Anesthetics □ Latex □ Penicillin/Antibiotics □ Other: ___________

Dental History

Current Dental Symptoms

• Pain Level (1-10): ____
• Duration of symptoms: ____
• Tooth sensitivity to: □ Hot □ Cold □ Pressure □ Sweets

Previous Dental Work

• Last dental visit: _________
• Previous root canals: □ Yes □ No
• Recent dental x-rays: □ Yes □ No

Authorization

I certify that the information provided is accurate and complete to the best of my knowledge.

Signature: _________________ Date: _________________