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. *