Patient Medical History
PHYSICIAN:
Date:
OFFICE PHONE:
LAST EXAM DATE:
Are you taking any medication, including non-prescription medicine?
If yes, list the medications here:
Yes □ No □
Have you been hospitalized for any surgical operation or serious illness in the last 5 years:
If yes, explain:
Yes □ No □
Are you allergic or have you had any reactions to the following?
Yes □
Yes □
Yes □
Yes □
Yes □
Local Anesthetics (e.g. Novocain)
Penicillin or other antibiotics
Sulfa Drugs
Barbiturates
Any Metals (nickel, mercury, etc)
Do you use tobacco?
Do you use controlled substances?
Women:
Yes □ No □
Yes □ No □
No □
No □
No □
No □
No □
Sedatives
Iodine
Aspirin
Latex Rubber
Other
Do you wear contacts?
Are you pregnant or do you think you are pregnant?
Are you taking oral contraceptives?
Are you nursing?
Yes □
Yes □
Yes □
Yes □
Yes □
No □
No □
No □
No □
No □
Yes □ No □
Yes □ No □
Yes □ No □
Yes □ No □
Please circle any of the following conditions that you have, or have had in the past:
High Blood Pressure
Low Blood Pressure
Heart Trouble
Heart Disease
Stroke
Heart Attack
Cardiac Pace Maker
Angina
Fainting/Seizures
Persistent Diarrhea
S. T. D.
Chest Pains
Heart Murmur
Mitral Valve Prolapse
Easily Winded
Hay Fever/Allergies
Asthma
Respiratory Problems
Rheumatic Fever
Hemophilia
Frequently Tired
AIDS or HIV
Joint Replacement /Implant
Emphysema
Cancer
Leukemia
Radiation Therapy
Kidney Disease
Liver Disease
Diabetes
Hepatitis/Jaundice
Recurrent Fevers
Other:
Thyroid Problem
Anemia
Arthritis
Glaucoma
Tuberculosis
Epilepsy/Convulsions
Swollen Ankles
Stomach Troubles/Ulcers
Recent Weight Loss
Chills/Night Sweats
Dental History
NAME OF PREVIOUS DENTIST:
DATE OF LAST EXAM:
Do your gums bleed while brushing/flossing?
Yes □ No □
Do you have frequent headaches?
Yes □
Are your teeth sensitive to hot or cold?
Yes □ No □
Do you clench or grind your teeth?
Yes □
Are your teeth sensitive to sweet or sour?
Yes □ No □
Do you bite your lips or cheeks?
Yes □
Have you injured your head, neck, or jaw?
Yes □ No □
Have you had orthodontic treatment?
Yes □
Do you wear dentures or partials?
Yes □ No □
Placement date:
Do you have any sores or lumps near or around your mouth?
Yes □
Have you ever had any prolonged bleeding following extractions?
Yes □
Have you ever received oral hygiene instructions regarding the care of your teeth and gums?
Yes □
Have you ever experienced any of the problems with your jaw? Please circle all that apply.
Clicking Pain (joint, ear, side of face)
Difficulty opening or closing
Difficulty chewing
Do you like your smile ☺ ?
No □
No □
No □
No □
No □
No □
No □
Yes □ No □ If no, explain:
I have truthfully answered all the above questions and agree to inform this office of any changes in my medical or dental
history.
Patient Signature or Responsible Party Signature if patient is a minor
Date