Medical History

Patient Information

Are you completing this form for another person? * YesNo

Filing Information

Your First Name *
Your Middle Name
Your Last Name *
What is your relationship to the patient? *
First Name *
Middle Name
Last Name *
SS# or Patient ID *
Birth Date *
Occupation *
Sex * MaleFemale
Height *
Weight *

Patient Contact Information

Email *
Cell Phone *
Home Phone
Street Address *
City *
State *
Zip Code *

Emergency Contact Information

Their First Name *
Their Middle Name
Their Last Name *
What is their relationship to the patient? *
Cell Phone *
Home Phone

Preliminary Medical Information

Does the patient have:

Active Tuberculosis *
YesNoNot Sure
Persistent cough greater than a 3 week duration *
YesNoNot Sure
Cough that produces blood *
YesNoNot Sure
Been exposed to anyone with Tuberculosis *
YesNoNot Sure

Dental Information

Do your gums bleed when you brush or floss? *
YesNoNot SureBLANK
Are your teeth sensitive to cold, hot, sweets or pressure? *
YesNoNot SureBLANK
Does food or floss catch between your teeth? *
YesNoNot SureBLANK
Is your mouth dry? *
YesNoNot SureBLANK
Have you had any periodontal (gum) treatments? *
YesNoNot SureBLANK
Have you ever had orthodontic (braces) treatment? *
YesNoNot SureBLANK
Have you had any problems associated with previous dental treatment? *
YesNoNot SureBLANK
Is your home water supply fluoridated? *
YesNoNot SureBLANK
Do you drink bottled or filtered water? *
YesNoNot SureBLANK
How often? *
DailyWeeklyOccasionallyBLANK
Are you currently experiencing dental pain or discomfort? *
YesNoNot SureBLANK
Do you have earaches or neck pains? *
YesNoNot SureBLANK
Do you have any clicking, popping or discomfort in the jaw? *
YesNoNot SureBLANK
Do you brux or grind your teeth? *
YesNoNot SureBLANK
Do you have sores or ulcers in your mouth? *
YesNoNot SureBLANK
Do you wear dentures or partials? *
YesNoNot SureBLANK
Do you participate in active recreational activities? *
YesNoNot SureBLANK
Have you ever had a serious injury to your head or mouth? *
YesNoNot SureBLANK
Date of your last dental exam *
Date of last dental x-rays? *
What was done at your last dental exam? *
What is the reason for visiting us? *
How do you feel about your smile? *

Medical Information

Are you now under the care of a physician? *
YesNoNot SureBLANK
Physician Name *
Physician's Phone *
Physician's Street Address *
Physician's City *
Physician's State *
Physician's Zip Code *
Are you in good health? *
YesNoNot SureBLANK
Has there been any change in your general health within the past year? *
YesNoNot SureBLANK
What condition is being treated? *
Date of your last physical exam *
Have you had a serious illness, operation or been hospitalized in the past 5 years? *
YesNoNot SureBLANK
What was the illness or problem? *
Are you taking or have you recently taken any prescription or over the counter medicine(s)? *
YesNoNot SureBLANK
Please list all, including vitamins, natural or herbal preparations and/or diet supplements *
Do you wear contact lenses? *
YesNoNot SureBLANK
Have you had an orthopedic total joint (hip, knee, elbow, finger) replacement? *
YesNoNot SureBLANK
Date of your Replacement? *
Have you had any complications? *
Are you taking or scheduled to begin taking either of the medications, alendronate (Fosamax®) or risedronate (Actonel®) for osteoporosis or Paget’s disease? *
YesNoNot SureBLANK
Since 2001, were you treated or are you presently scheduled to begin treatment with the intravenous bisphosphonates (Aredia® or Zometa®) for bone pain, hypercalcemia or skeletal complications resulting from Paget’s disease, multiple myeloma or metastatic cancer? *
YesNoNot SureBLANK
Date Treatment began: *
Do you use controlled substances (drugs)? *
YesNoNot SureBLANK
Do you use tobacco (smoking, snuff, chew, bidis)? *
YesNoNot SureBLANK
How interested are you in stopping? *
VerySomewhatNot InterestedBLANK
Do you drink alcoholic beverages? *
YesNoNot SureBLANK
How much alcohol did you drink in the last 24 hours? *
How much do you typically drink in a week? *
Are you pregnant? *
YesNoNot SureBLANK
Number of weeks? *
Are you taking birth control pills or hormonal replacement *
YesNoNot SureBLANK
Are you nursing? *
YesNoNot SureBLANK

Allergies

Are you allergic to or have you had a reaction to the following?
Local anesthetics: *
YesNoNot SureBLANK
Please specify type of reaction *
Aspirin: *
YesNoNot SureBLANK
Please specify type of reaction *
Penicillin or other antibiotics: *
YesNoNot SureBLANK
Please specify type of reaction *
Barbiturates, sedatives, or sleeping pills: *
YesNoNot SureBLANK
Please specify type of reaction *
Sulfa drugs: *
YesNoNot SureBLANK
Please specify type of reaction *
Codeine or other narcotics: *
YesNoNot SureBLANK
Please specify type of reaction *
Metals: *
YesNoNot SureBLANK
Please specify type of reaction *
Latex (rubber): *
YesNoNot SureBLANK
Please specify type of reaction *
Iodine: *
YesNoNot SureBLANK
Please specify type of reaction *
Hay fever/seasonal: *
YesNoNot SureBLANK
Please specify type of reaction *
Animals: *
YesNoNot SureBLANK
Please specify type of reaction *
Food: *
YesNoNot SureBLANK
Please specify type of reaction *
Other: *
YesNoNot SureBLANK
Please specify type of reaction *

Medical History

Have you had any of the following diseases or problems?
Artificial (prosthetic) heart valve: *
YesNoNot SureBLANK
Previous infective endocarditis: *
YesNoNot SureBLANK
Damaged valves in transplanted heart: *
YesNoNot SureBLANK
Congenital heart disease (CHD)
Unrepaired, cyanotic CHD: *
YesNoNot SureBLANK
Repaired (completely) in last 6 months: *
YesNoNot SureBLANK
Repaired CHD with residual defects: *
YesNoNot SureBLANK
Except for the conditions listed above, antibiotic prophylaxis is no longer recommended for any other form of CHD.
Cardiovascular disease: *
YesNoNot SureBLANK
Angina: *
YesNoNot SureBLANK
Arteriosclerosis: *
YesNoNot SureBLANK
Congestive heart failure: *
YesNoNot SureBLANK
Damaged heart valves: *
YesNoNot SureBLANK
Heart attack: *
YesNoNot SureBLANK
Heart murmur: *
YesNoNot SureBLANK
Low blood pressure: *
YesNoNot SureBLANK
High blood pressure: *
YesNoNot SureBLANK
Other congenital heart defects: *
YesNoNot SureBLANK
Mitral valve prolapse: *
YesNoNot SureBLANK
Pacemaker: *
YesNoNot SureBLANK
Rheumatic fever: *
YesNoNot SureBLANK
Rheumatic heart disease: *
YesNoNot SureBLANK
Abnormal bleeding: *
YesNoNot SureBLANK
Anemia: *
YesNoNot SureBLANK
Blood transfusion: *
YesNoNot SureBLANK
Date of transfusion: *
Hemophilia: *
YesNoNot SureBLANK
AIDS or HIV infection: *
YesNoNot SureBLANK
Arthritis: *
YesNoNot SureBLANK
Autoimmune disease: *
YesNoNot SureBLANK
Rheumatoid arthritis: *
YesNoNot SureBLANK
Systemic lupus erythematosus: *
YesNoNot SureBLANK
Asthma: *
YesNoNot SureBLANK
Bronchitis: *
YesNoNot SureBLANK
Emphysema: *
YesNoNot SureBLANK
Sinus trouble: *
YesNoNot SureBLANK
Tuberculosis: *
YesNoNot SureBLANK
Cancer/Chemotherapy/Radiation Treatment: *
YesNoNot SureBLANK
Chest pain upon exertion: *
YesNoNot SureBLANK
Chronic pain: *
YesNoNot SureBLANK
Diabetes Type I or II: *
YesNoNot SureBLANK
Eating disorder: *
YesNoNot SureBLANK
Malnutrition: *
YesNoNot SureBLANK
Gastrointestinal disease: *
YesNoNot SureBLANK
G.E. Reflux/persistent heartburn: *
YesNoNot SureBLANK
Ulcers: *
YesNoNot SureBLANK
Thyroid problems: *
YesNoNot SureBLANK
Stroke: *
YesNoNot SureBLANK
Glaucoma: *
YesNoNot SureBLANK
Hepatitis, jaundice or liver disease: *
YesNoNot SureBLANK
Epilepsy: *
YesNoNot SureBLANK
Fainting spells or seizures: *
YesNoNot SureBLANK
Neurological disorders: *
YesNoNot SureBLANK
Please specify: *
Sleep disorder: *
YesNoNot SureBLANK
Mental Health disorders: *
YesNoNot SureBLANK
Please specify: *
Recurrent Infections: *
YesNoNot SureBLANK
Type of Infection: *
Kidney problems: *
YesNoNot SureBLANK
Night sweats: *
YesNoNot SureBLANK
Osteoporosis: *
YesNoNot SureBLANK
Persistent swollen glands in neck: *
YesNoNot SureBLANK
Severe headaches/migraines: *
YesNoNot SureBLANK
Severe or rapid weight loss: *
YesNoNot SureBLANK
Sexually transmitted disease: *
YesNoNot SureBLANK
Excessive urination: *
YesNoNot SureBLANK
Do you have any disease, condition, or problem not listed above that you think I should know about?: *
YesNoNot SureBLANK
Please explain: *
Has a physician or previous dentist recommended that you take antibiotics prior to your dental treatment? *
YesNoNot SureBLANK
Name of physician or dentist making recommendation: *
Physician or Dentist's Phone: *

Submit

NOTE: Both Doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment.
I certify that I have read and understand the above and that the information given on this form is accurate. I understand the importance of a truthful health history and that my dentist and his/her staff will rely on this information for treating me. I acknowledge that my questions, if any, about inquiries set forth above have been answered to my satisfaction. I will not hold my dentist, or any other member of his/her staff, responsible for any action they take or do not take because of errors or omissions that I may have made in the completion of this form. *