DENTAL HEALTH HISTORY
Personal Information
Name:
Date:
I prefer to be called:
Chart Number:
Birthday (MM/DD/YYYY):
/
/
Male
_Female
Home Phone: (
)
Work Phone: (
)
Mobile Phone: (
)
Other Phone: (
)
List other family members that are seen in our dental clinic:
What was the date of your last dental visit? (MM/DD/YYYY):
Do you have any learning disabilities?
YES
/
/
NO (If yes, please list):
Do you use any assistive devices? (i.e. hearing aids, glasses)
YES
NO (If yes, please list):
What is the reason for your dental visit today? (i.e. cleaning, pain, routine visit, etc…):
Have you ever had a serious/difficult problem associated with any previous dental work?
YES
(If yes, please explain):
Do you experience jaw joint discomfort (TMJ, TMD)?
How would you rate your current dental health?
YES
GOOD
NO
FAIR
POOR
MEDIUM
HARD
How many times a day do you brush?
What type of tooth brush bristles do you use?
Do you floss?
YES
SOFT
NO (If yes, how many times a day?):
Do you like to SMILE?
YES
NO
***In case of EMERGENCY, who should we contact?***
Name:
Relationship:
Home Phone: (
)
Work Phone: (
)
Mobile Phone: (
)
Other Phone: (
)
NO
MEDICAL HISTORY
Do you have a personal physician?
Office Phone: (
YES
NO (If yes, who?):
)
Date of last visit:
How would you rate your current health?
GOOD
FAIR
Is your physician treating you for a specific condition?
/
/
POOR
YES
NO (If yes, please explain):
Please list all current medications and dosages you are taking:
COFMC Medical Patients: we will access your medical chart with your permission to attain a list of your current
medications. Please indicate this my initialing here: ____________, and you may bypass the above list.
FEMALES ONLY
Are you currently pregnant?
Are you nursing?
YES
YES
NO (If yes, how many weeks?):
NO
Are you taking birth control pills?
N/A
YES
NO
***REQUIRED FOR ALL PATIENTS***
CARDIOVASCULAR:
Heart Failure
Heart disease/attack
Angina pectoris chest pain
High Blood Pressure
Low blood pressure
Heart Murmur
Mitral valve prolapsed
Rheumatic fever
Congenital heart defect
Artificial heart valve
Arrhythmias
Heart pacemaker/defibrillator
Heart transplant
Heart surgery
Prior Phen-Fen use
Stroke
Aneurysm
Other Heart problems (Explain):
Hemophilia
Leukemia
HEMATOLOGIC:
Blood transfusion
Anemia
Sickle cell disease
Tendency to bleed longer
***REQUIRED FOR ALL PATIENTS CONTINUED***
NEURAL AND SENSORY:
Eye pain
Vision problems
Glaucoma or cataracts
Earaches
Ringing in ears
Hearing loss
Severe headaches
Fainting/dizziness
Epilepsy
Nervousness
Psychiatric treatment
Developmental delay
Stomach ulcers
Gastritis
Colitis
Persistent diarrhea
Liver disease
Jaundice
Cirrhosis
GASTROINTESTINAL:
Hepatitis (Circle one) HEP A
HEP B
HEP C
RESPIRATORY:
Hay fever
Sinusitis
Seasonal allergies
Asthma
Chronic cough
Emphysema
Tuberculosis (TB)
Breathing difficulty (COPD)
Diabetes
Insulin-dependent (IDDM)
Non-insulin dependent (NIDDM)
Thyroid disease
Hyper-thyroidism
Hypo-thyroidism
Bladder problems
HIV Positive
Supplemental oxygen
ENDOCRINE:
URINARY/SEXUALLY TRANSMITTED DISEASES:
Frequent urination
Kidney problems
Sexually transmitted disease (STD)(List all that apply):
DERMAL/SKELETAL:
Latex allergy
Abnormal mole
Osteoporosis
Sore muscles
Stiff joints
Arthritis
Artificial joint
Fever blisters
Mouth ulcers (canker sores)
OTHER CONDITIONS:
Frequent sore throat
Enlarged lymph node
Tumor or cancer
Radiation treatment
Chemotherapy
Surgical removal of tumor
Alcohol use
Drug addiction
Steroid therapy
Tobacco use (Circle one):
Current
Former
(If yes): How many packs per day:
Never
How many years of use:
Other conditions (Please list):
***REQUIRED FOR ALL PATIENTS***
Please let us know if you have any drug allergies. (Check all that apply and list any not listed):
Aspirin
Codeine
Penicillin
Tetracycline
Latex
Dental anesthetic:
Sulfa
Other (Please list):
If you have no known drug allergies (NKDA), please indicate with your initials and date:
Initials
Date
I understand that the information I have provided today is correct to the best of my knowledge. I also understand that this
information will be held in the strictest confidence and it is my responsibility to inform Central Oklahoma Family Medical
Center of any changes in my medical/dental status.
I authorize the dental staff to perform any necessary dental services that I may need during diagnosis and treatment with my
informed consent.
By signing below, I acknowledge that at my triage (treatment planning) appointment, definitive treatment (extraction,
filling, etc.) may or may not be rendered. I also understand that if I am more than 10 minutes late to my designated
appointment time, my appointment may be rescheduled.
Patient (or Guardian, if under the age of 18) Signature:
__________________Date: _________________
FOR CLINIC STAFF USE ONLY:
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