Concept Dentistry
MEDICAL HISTORY
PATIENT NAME _______________________________________________ Birth Date _____________________________________
Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may
have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the
following questions.
Are you under a physician's care now?
Have you ever been hospitalized or had a major operation?
Have you ever had a serious head or neck injury?
Are you taking any medications, pills, or drugs?
Have you had any joint replacements?
Are you on any anticoagulant medication (includes Aspirin)?
Do you use tobacco?
Do you use controlled substances?
Do you need to pre-medicate?
Women: Are you
Pregnant/Trying to get pregnant?
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
Taking oral contraceptives?
If yes, please explain: ___________________________________
If yes, please explain: ___________________________________
If yes, please explain: ___________________________________
If yes, please explain: ___________________________________
If yes, date and type: ____________________________________
If yes, please explain:____________________________________
If yes, please explain: ___________________________________
Yes
No
Nursing?
Yes
No
Are you allergic to any of the following?
Aspirin
Other
Penicillin
Codeine
Acrylic
Metal
Latex
Local Anesthetics
Sulfa Drugs
If yes, please explain:
Do you have, or have you had, any of the following?
AIDS/HIV Positive
Yes
Alzheimer's Disease
Yes
Anaphylaxis
Yes
Anemia
Yes
Angina
Yes
Arthritis/Gout
Yes
Artificial Heart Valve
Yes
Artificial Joint
Yes
Asthma
Yes
Blood Disease
Yes
Blood Transfusion
Yes
Breathing Problem
Yes
Bruise Easily
Yes
Cancer
Yes
Chemotherapy
Yes
Chest Pains
Yes
Cold Sores/Fever Blisters Yes
Congenital Heart Disorder Yes
Convulsions
Yes
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Cortisone Medicine
Yes
Diabetes
Yes
Drug Addiction
Yes
Easily Winded
Yes
Emphysema
Yes
Epilepsy or Seizures
Yes
Excessive Bleeding
Yes
Excessive Thirst
Yes
Fainting Spells/Dizziness Yes
Frequent Cough
Yes
Frequent Diarrhea
Yes
Frequent Headaches
Yes
Genital Herpes
Yes
Glaucoma
Yes
Hay Fever
Yes
Heart Attack/Failure
Yes
Heart Murmur
Yes
Heart Pace Maker
Yes
Heart Trouble/Disease Yes
Have you ever had any serious illness not listed above?
Yes
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Hemophilia
Hepatitis A
Hepatitis B or C
Herpes
High Blood Pressure
Hives or Rash
Hypoglycemia
Irregular Heartbeat
Kidney Problems
Leukemia
Liver Disease
Low Blood Pressure
Lung Disease
Mitral Valve Prolapse
Pain in Jaw Joints
Parathyroid Disease
Psychiatric Care
Radiation Treatments
Recent Weight Loss
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
Renal Dialysis
Yes
Rheumatic Fever
Yes
Rheumatism
Yes
Scarlet Fever
Yes
Shingles
Yes
Sickle Cell Disease
Yes
Sinus Trouble
Yes
Spina Bifida
Yes
Stomach/Intestinal Disease Yes
Stroke
Yes
Swelling of Limbs
Yes
Thyroid Disease
Yes
Tonsillitis
Yes
Tuberculosis
Yes
Tumors or Growths
Yes
Ulcers
Yes
Venereal Disease
Yes
Yellow Jaundice
Yes
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
If yes, please explain: __________________________________________
Comments/Additional Medications:
_____________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________
To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can
be dangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in medical status.
SIGNATURE OF PATIENT, PARENT, or GUARDIAN __________________________________________________ DATE ______________________