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Medical History
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- Patient Information
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Patient Name
*
First
Last
Birthdate
*
MM slash DD slash YYYY
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Today's Date
MM slash DD slash YYYY
Gender
*
Male
Female
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Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be talking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions.
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Do you take any type of blood thinners? (Ex: Cumodin, Plavix, Aspirin, etc.)
*
Yes
No
If yes, What blood thinner?
*
Do you have any artificial joints?
*
Yes
No
If Yes, Specify joint, and What Year?
*
Are you under a physiciian's care now?
*
Yes
No
If Yes, Please mention Dr Name and Phone Number
*
Have you ever been hospitalized or had a major operation?
*
Yes
No
If Yes, What operation? When?
*
Have you ever had a serious head or neck injury?
*
Yes
No
If Yes, Please Specify
*
Are you taking any medications, pills, or drugs?
*
Yes
No
If Yes, Please mention All what you take
*
Do you take, or have you taken, Phen-Fen or Redux?
*
Yes
No
If Yes, Please specify
*
From / To
Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates?
*
Yes
No
If Yes, Please specify
*
From/To
Are you on special diet?
*
Yes
No
If Yes
*
Women: Are you
Pregnant/Trying to get pregnant
Nursing
Taking oral contraceptives
Are you allergic to any of the following?
Aspirin
Metal
Pencillin
Latex
Codeine
Sulfa Drugs
Arcylic
Local Anesthetics
Any other allergies/medications?
*
Yes
No
If Yes, Please specify
*
Do you use controlled substances?
*
Yes
No
If Yes, please specify
*
From/To
*
Do you have, or have you had, any of the following?
AIDS/HIV Positive
*
Yes
No
Alzheimer's Disease
*
Yes
No
Anaphylaxis
*
Yes
No
Anemia
*
Yes
No
Angina
*
Yes
No
Arthritis/Gout
*
Yes
No
Artificial HeartValve
*
Yes
No
Excessive Thirst
*
Yes
No
Fainting Spells/Dizziness
*
Yes
No
Frequent Cough
*
Yes
No
Frequent Diarrhea
*
Yes
No
Frequent Headaches
*
Yes
No
Genital Herpes
*
Yes
No
Giaucoma
*
Yes
No
Hay Fever
*
Yes
No
Heart Attack/Failure
*
Yes
No
Heart Murmur
*
Yes
No
Pacemaker/Defibrillator
*
Yes
No
Heart Trouble/Disease
*
Yes
No
Back Problems
*
Yes
No
Headaches
*
Yes
No
Shortness of Breath
*
Yes
No
Cortisone Medicine
*
Yes
No
Diabetes
*
Yes
No
Drug Addiction
*
Yes
No
Easily Winded
*
Yes
No
Emphysema
*
Yes
No
Epilepsy or Seizures
*
Yes
No
Excessive Bleeding
*
Yes
No
Hypoglycemia
*
Yes
No
Irregular Heartbeat
*
Yes
No
Kidney Problems
*
Yes
No
Leukemia
*
Yes
No
Liver Disease
*
Yes
No
Low Blood Pressure
*
Yes
No
Lung Disease
*
Yes
No
Mitral Valve Prolapse
*
Yes
No
Osteoporosis
*
Yes
No
Pain in Jaw Joints
*
Yes
No
Parathyroid Disease
*
Yes
No
Bleeding Abnormally
*
Yes
No
Hernia Repair
*
Yes
No
Skin Rash
*
Yes
No
Hemophilia
*
Yes
No
Hepatitis A
*
Yes
No
Hepatitis B or C
*
Yes
No
Herpes
*
Yes
No
High Blood Pressure
*
Yes
No
High Cholesterol
*
Yes
No
Hives or Rash
*
Yes
No
Sickle Cell Disease
*
Yes
No
Sinus Trouble
*
Yes
No
Spina Bifida
*
Yes
No
Stomach/Intestinal Disease
*
Yes
No
Stroke
*
Yes
No
Swelling of Limbs
*
Yes
No
Thyroid Disease
*
Yes
No
Tonsilllitis
*
Yes
No
Tuberculosis
*
Yes
No
Tumors or Growths
*
Yes
No
Ulcers
*
Yes
No
Venereal Disease
*
Yes
No
Cough, Persistent
*
Yes
No
Jaw Pain
*
Yes
No
Tobacco Habit
*
Yes
No
Radiation Treatments
*
Yes
No
Recent WeightLoss
*
Yes
No
Renal Dialysis
*
Yes
No
Rheumatic Fever
*
Yes
No
Rheumatism
*
Yes
No
Scarlet Fever
*
Yes
No
Shingles
*
Yes
No
Asthma
*
Yes
No
Blood Disease
*
Yes
No
Blood Transfusion
*
Yes
No
Breathing Problems
*
Yes
No
Btuise Easily
*
Yes
No
Cancer
*
Yes
No
Chemotherapy
*
Yes
No
Chest Pains
*
Yes
No
Cold Sores/Fever Blisters
*
Yes
No
Congenital Heart Disorder
*
Yes
No
Convulsions
*
Yes
No
Yellow Jaundice
*
Yes
No
Cough upblood
*
Yes
No
Respiratory Disease
*
Yes
No
Signature
Date
MM slash DD slash YYYY
