Patient Name_______________________________________________________Date____________________________________ HEALTH HISTORY There are many medical situations which can affect, or be affected by the procedures or drugs used for dentistry. Please complete the following questionnaire carefully. Thank you. 1. Physician’s name and phone number_________________________________________Date of last medical exam_________________________ 2. Are you currently under the care of a physician?........................................................................................................................ Yes___ No___ 3. Have you been hospitalized or had a serious illness within the past 5 years?……………………………………………………………………….. Yes___ No___ 4. (a)Are you currently taking any medications?...........................................................................................................Yes___ No___ If yes, please list:___________________________________________________________________________ (b) Are you taking any supplements?....................................................................................................................... Yes___ No___ If yes, please list:___________________________________________________________________________ 5. Are you allergic or have you reacted adversely to any of the following medications?........................................... Yes___ No___ (X if yes) Aspirin Nitrous Oxide Tetracycline Penicillin Codeine Erythromycin Novacaine/Xylocaine Valium 6. Are you aware of being allergic to any other medication or substance?................................................................ Yes___ No___ If yes, please list:____________________________________________________________________________________________ 7. Have you ever had any of the following conditions? (X if yes)…………………………………………………………………………………………………………. ___ Heart Trouble ___ Radiation Therapy ___ Hepatitis ___AIDS or AIDS related syndrome ___ Heart Attack ___ Arthritis ___ Diabetes ___Emotional/Psychiatric Disorders ___ Heart murmur ___ Asthma ___ Anemia ___Alcoholism ___ Artificial Heart Valves ___ Kidney Disease ___ Convulsions ___Chemical Dependency ___ Stroke ___ Tuberculosis ___ Venereal Disease ___Women only: Pregnant? Mo.___ ___ High Blood Pressure ___ Ulcers ___ Artificial Joints ___ Rheumatic Fever ___ Jaundice ___ Malignancies ___ Bleeding Problems ___ Epilepsy ___ Osteoporosis ___ Blood Transfusions ___ History of Fainting ___ Autoimmune Disease ___ Tumor or Growth ___ Respiratory Disease ___ Thyroid Disease 8. Do you have any other disease, condition, or problem not listed above that you think we should be aware of? If yes, please explain________________________________________________________________________ 9. Do you get up often at night to urinate?.................................................................................................................. 10. Are you thirsty much of the time?............................................................................................................................ 11. Has anyone in your family had diabetes?................................................................................................................. 12. Do you consider yourself a nervous person?............................................................................................................ 13. Do you smoke? If yes, how much?_____________________________________________________________ Yes___ No___ Yes___ Yes___ Yes___ Yes___ Yes___ No___ No___ No___ No___ No___ DENTAL HISTORY 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. Why are you now seeking dental treatment?_____________________________________________________________________ Name of Previous Dentist & Date of last dental exam:______________________________________________________________ Major dental work done in the past:____________________________________________________________________________ Reason for leaving previous dentist:____________________________________________________________________________ Are you satisfied with your past dentistry? …………………………………………………………………………................................. Yes___ No___ Are you satisfied with the appearance of your teeth? …………………………………………………………………………………………. Yes___ No___ Do you brush and floss daily?.....................................................................................................................................Yes___ No___ Do your gums bleed?................................................................................................................................................. Yes___ No___ Does food wedge between your teeth?.................................................................................................................... Yes___ No___ Do you grind or clench your teeth?........................................................................................................................... Yes___ No___ Do you hear popping or clicking, or feel pain around your ears while chewing?...................................................... Yes___ No___ Have you ever had gum treatment?.......................................................................................................................... Yes___ No___ Have you ever had orthodontic treatment?.............................................................................................................. Yes___ No___ Do you have swelling, lumps, or sore spots in your mouth?.................................................................................... Yes___ No___ Do you have difficulty opening wide?....................................................................................................................... Yes___ No___ Do sweets, cold, heat, or chewing cause pain?......................................................................................................... Yes___ No___ Do you have a fear of having dentistry done?........................................................................................................... Yes___ No___ Are you available for appointments on short notice?............................................................................................... Yes___ No___