guterdentalcenter.com-Dental and Medical History

Dental and Medical History
Patient Name

First NameLast Name
Date

MonthDayYear
Primary reason for this dental appointment

ExaminationEmergencyConsultation
Dental History
Do you have a specific dental problem?

YesNo
If yes, Describe:
Do you have dental examinations on a routine basis?

YesNo
If yes, Last visit :
Do you think you have active decay or gum disease?

YesNo
Do you brush and floss on a routine basis?

YesNo
Discuss:
Do your gums ever bleed?

YesNo
Discuss:
Do you like your smile?

YesNo
If yes, Why?
Does food catch between your teeth?

YesNo
Any loose teeth?
Do you want to keep your remaining teeth?

YesNo
Do you want to keep your remaining teeth?

YesNo
Do you brux or grind?
Have your past experiences in a dental office always been positive?

YesNo
Do you smoke or chew? Any sores or growths in your mouth?

YesNo
Discuss:
Name of previous dentist (optional) :
Date of last full mouth x-rays (16 small films or panoramic):

MonthDayYear
Date
Medical History
Are you under a physician's care now?

YesNo
Why?
Who?
Phone Number

Area CodePhone Number
Have you ever been hospitalized or had a major operation?

YesNo
Discuss:
Have you ever had a serious injury to your head or neck?

YesNo
Discuss:
Are you taking any medications, aspirin, vitamins, herbals, pills or drugs?

YesNo
If yes, What?
Are you on a special diet?

YesNo
If yes, Discuss:
Are you allergic to any medications or substances?

YesNo
Please check box below

AspirinPenicillinCodeineAcrylicMetalLatex RubberMilkOther
Women (Please check):

Pregnant/trying to get pregnantNursingTaking oral contraceptives
Discuss:
Do you now have or have you ever had any of the following? Please check appropriate boxes. 'If yes to any of the starred conditions, please call prior to your appointment .. premedication or changes In medication may be required.

Heart Disease/SurgeryHeart Murmur or DefectIrregular Heart BeatAngina/Chest PainHeart Attack/FailureCongenital Heart DisorderMitral Valve ProlapseScarlet FeverRheumatic FeverArtificial Heart ValveHeart Pace MakerPulmonary ShuntHigh Blood PressureLow Blood PressureBacterial EndocarditisUnexplained FeverBruise Easily/Blood DiseaseAnemiaExcessive BleedingSickle Cell DiseaseHemophilia (Bleeding Problem)LeukemiaRecent Blood TransfusionSwelling of LimbsLung DiseaseBreathing ProblemShortness of BreathFrequent CoughHay FeverSinus TroubleAsthmaBloody SputumEmphysemaTuberculosisCancerX-Ray Treatments (Radiation)ChemotherapyOsteoporosisBisphosphonatesOsteonecrosis of JawAredia I.V.Zometa I.V.Fosamax, Actonel, BonivaStomach/Intestinal DiseaseUlcersRecent Weight LossDiarrheaExcessive ThirstHypoglycemiaLiver DiseaseHepatitis A (Infectious)Hepatitis B or CNight SweatsYellow JaundiceKidney ProblemsRenal DialysisThyroid DiseaseParathyroid DiseaseArthritis/GoutRheumatismPain in Jaw JointsCortisone MedicineArtificial JointsVenereal DiseaseAIDSHIV PositiveGenital HerpesDrug Addiction/AlcoholismTattoos/Body PiercingCold SoresFever BlistersHerpesStrokeConvulsionsEpilepsy or SeizureFainting or DizzinessGlaucomaTumors or GrowthsNervousnessPsychiatric CareAlzheimer's DiseaseAllergies (Medicines)Allergies (Pollen/ Dust)Hives or RashNeed Premedication?Ever taken fen-phen ?Cochlear implants?
Have you ever had any other serious illness not checked above?

YesNo
Discuss?
Do you wish to talk to the dentist privately about any problem?

YesNo
To the best of my knowledge, all the preceding answers are correct. If I have any changes in my health status or if my medicines change, I shall inform Ihe dentist and staff at the next appointment without fail.
PATIENT SIGNATURE (PARENT OR GUARDIAN)

Clear
Date

MonthDayYear
Date
Reviewed By Doctor
Date

MonthDayYear
Date
BP
Pulse
History Review and Significant Findings
Medical Updates
I have read my MEDICAL HISTORY dated and confirm that it adequately states past and present conditions.

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