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
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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___