Please fill out the second form

Please fill out the second form: Medical History Jefferson M. Sims, DMD PA
Thank you for accurately completing this form. Please be assured that your entries are for our records only, and will be considered confidential. During your initial visit, or during medical history update visits, you will be asked additional questions about your personal and/or medical history; again, your answers are kept in strict confidence.
First and Last Name:
Today's date:
Email Address:
Are you in good health?	Yes No
Has there been any change in your health in the last year?	Yes No
Please enter the date (approximate is OK) of your last complete physical examination:
Are you currently under the care of a physician?	Yes No
If “Yes”, please state the condition(s) for which you’re being treated:
Over the last five years, have you experienced any serious illness?	Yes No
Over the last five years, have you experienced any any operations?	Yes No
Over the last five years, have you experienced any hospitalizations?	Yes No
If “Yes”, please state the nature of the illness or problem:
Are you currently taking any medications, either prescription or non-prescription?	Yes No
If “Yes”, please enter/list your medication(s):
Do you have, or have you ever had, any of the following diseases or problems (Please check all that apply)?	Damaged Heart Valves Artificial Heart Valves Heart Murmur Rheumatic Fever Heart Trouble Heart Attack Angina Coronary Insufficiency High Blood Pressure Arteriosclerosis Stroke None
Do you have chest pain upon exertion?	Yes No
Are you ever short of breath after mild exercise, or when lying down?	Yes No
Do your ankles ever swell?	Yes No
Do you have inborn heart defects?	Yes No
Do you have a cardiac pacemaker?	Yes No
Do you have allergies to medications, or to environmental substances?	Yes No
Do you have sinus problems?	Yes No
Do you have asthma or hay fever?	Yes No
Do you suffer fainting spells, or seizures?	Yes No
Do you suffer persistent diarrhea?	Yes No
Has there been a change in your weight over the last year (check all that apply)?	Yes No Gain Loss
Are you diabetic?	Yes No
Have you ever had hepatitis, jaundice, or liver disease?	Yes No
Have you been diagnosed with AIDS, or HIV infection?	Yes No
Do you have respiratory problems?	Yes No
Do you have arthritis, or painful, swollen joints?	Yes No
Do you suffer from stomach ulcers, hyperacidity, heartburn, or acid reflux?	Yes No
Do you have kidney problems, or urinary tract problems?	Yes No
Do you have a persistent cough?	Yes No
Do you have a cough that produces blood?	Yes No
Do you have persistent swollen glands in your neck?	Yes No
Do you have, have you had, or have you tested positively for tuberculosis?	Yes No
Is your blood pressure persistently low?	Yes No
Do you have, or have you ever had, a sexually transmitted disease?	Yes No
Do you have, or have you ever had, seizures, epilepsy, or any other neurological disease?	Yes No
Do you have, or have you ever had, any tumors, growths, or cancer?	Yes No
Do you have, or have you ever had, any diagnosed mental health problems?	Yes No
Do you have persistent headaches, including migraine or cluster headaches?	Yes No
Have you ever had problems of the immune system?	Yes No
Have you ever had abnormal bleeding?	Yes No
Have you ever required a blood transfusion?	Yes No
Do you have any blood disorders, such as anemia?	Yes No
Have you ever had a reaction to any drug or medication, including dental anesthetics, general anesthetics, antibiotics, or pain medications?	Yes No
If “Yes”, please describe:
Have you ever had any problems associated with dental treatment?	Yes No
If “Yes”, please describe:
Do you have any disease, condition, or problem not addressed on this form that you feel we should know about?	Yes No
Are you wearing contact lenses?	Yes No
Are you wearing removable dental appliances or prosthetics?	Yes No
Women:
Are you pregnant?	Yes No
If “Yes”, for how many months have you been pregnant?
Do you have any problems associated with your menstrual periods?	Yes No
Are you nursing?	Yes No
Are you taking Birth Control Pills?	Yes No
Have you been told by a medical practitioner that there are any limitations on the type of dental treatment you may undergo?	Yes No
*Everyone:*
Please state your chief dental complaint:
You have completed the Medical History Form. Please click the "Submit Form" button. (Note: There are two forms to be filled out: Dental History and Medical History. If you've already filled out and submitted both of those forms, you should receive two confirmation emails.) Thank you for your time and patience!