Holland family Dentistry
MEDICAL HISTORY QUESTIONNAIRE
Name
Date of Birth
Allergic to: Local Anesthetic . . . . . . . . . . . . . .
Antibiotics. . . . . . . . . . . . . . . . . . .
Latex. . . . . . . . . . . . . . . . . . . . . . .
Other. . . . . . . . . . . . . . . . . . . . . . .
Age
Occupation
Answer Yes or No (check appropriate box)
Have you ever been diagnosed with:
High blood pressure . . . . . . . . . . . . . . . . . . . .
Heart disease – angina. . . . . . . . . . . . . . . . . .
- heart attack. . . . . . . . . . . . . .
- irregular heart beat . . . . . . . .
- heart murmur. . . . . . . . . . . . .
- rheumatic heart disease . . . .
- other . . . . . . . . . . . . . . . . . . .
Diabetes . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Lung disease – asthma. . . . . . . . . . . . . . . . . .
- emphysema. . . . . . . . . . . . . .
- pneumonia. . . . . . . . . . . . . . .
- bronchitis. . . . . . . . . . . . . . . .
Bleeding or Clotting disorder . . . . . . . . . . . . .
Hepatitis. . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Psychiatric problems - anxiety. . . . . . . . . . . .
- other. . . . . . . . . . . . . .
Nervous system disease - depression . . . . . .
- epilepsy . . . . . . . .
- migraines . . . . . . .
- other. . . . . . . . . . .
Kidney disease. . . . . . . .. . . . . . . . . . . . . . . . .
Gastrointestinal disease. . . . . . . . . . . . . . . . .
Aids or HIV Infection. . . . . . . . . . . . . . . . . . . .
Joint Replacement . . . . . . . . . . . . . . . . . . . . .
Are you or Could you be pregnant . . . . . . . . .
Are you taking birth control pills . . . . . . . . . . .
Other medical problems . . . . . . . . . . . . . . . . .
Please list
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Physician’s
Name
Phone Number
List all medications you are taking
List past surgical procedures:
When was your last dental visit?
Previous Dentist Name
How often do you brush your teeth?
How often do you floss your teeth?
When was your last Full Mouth X-Ray taken?
Notes:
Please list other medical problems
Do you smoke
Yes
No – If yes, how much
Do you use alcohol or recreational drugs
Do you regularly use aspirin
Dr./Hygienist Notes:
Yes
Yes
Yes
Yes
Yes
Yes
for how long
No – If yes, how much
No – If yes, how much
_how often
how often
No
No
No
No