Patient Medical History - Roberts Dentistry

MEDICAL AND DENTAL HEALTH HISTORY

Please fully complete the applicable fields below so that we can best serve you!
Patient Name*
Birth Date*

MonthDayYear
Date
Physician's Name*
Phone #
Format: (000) 000-0000.
Date of Last Visit

MonthDayYear
Date
Have you had any serious operations?*

YesNo
Please list any serious operations:
Leave this blank if it does not apply to you.
Are you pregnant?*

YesNo
If you are pregnant, what is your due date?

MonthDayYear
Date
Are you nursing?*

YesNo
Are you taking birth control medication?*

YesNo
Are you allergic to any of the following?*

AspirinPenicillinCodeineAcrylicMetalLatexSulfa DrugsLocal AnestheticsOtherNone of the above
Are you taking any medications, pills, drugs, or controlled substances?*

YesNo
Please list any medications, pills, drugs, or controlled substances you are taking:
Leave this blank if it does not apply to you.
Do you use tobacco?*

YesNo
Are you on a special diet?*

YesNo
Do you have any of the following (please check all that apply):*

AIDS/HIV PositiveDiabetesHemophiliaRadiation TreatmentsAlzheimer's DiseaseDrug AddictionEasily WindedEmphysemaEpilepsy or SeizuresExcessive BleedingFainting Spells/DizzinessFrequent CoughFrequent DiarrheaFrequent HeadachesGenital HerpesGlaucomaHepatitis AHepatitis B or CHerpesHigh Blood PressureHigh CholesterolHives or RashRecent Weight LossRenal DialysisRheumatic FeverAnaphylaxisAnemiaAnginaArthritis/GoutRheumatismScarlet FeverArtificial JointShinglesSickle Cell DiseaseAsthmaHypoglycemiaIrregular HeartbeatLeukemiaBlood DiseaseSinus TroubleBlood TransfusionSpina BifidaBreathing ProblemsLiver DiseaseBruise EasilyCancerMitral Valve ProlapseOsteoporosisPain in Jaw JointsLow Blood PressureStrokeLung DiseaseSwelling of LimbsThyroid DiseaseTonsillitisChemotherapyHay FeverCold Sore/Fever BlistersHeart MurmurTuberculosisCongenital Heart DisorderHeart PacemakerParathyroid DiseaseUlcersHeart Trouble/DiseaseVenereal DiseaseUlcersAnxiety/DepressionTMJYellow JaundiceStomach/Intestinal DiseasePsychiatric CareConvulsionsHeart Attack/FailureChest PainsCortisone MedicineNone of the above
Have you ever had any serious illnesses not listed?*

Yes, explain belowNo
Explain your serious illness not listed above:
Leave this blank if it does not apply to you.
Have you ever had a serious head or neck injury?*

Yes, explain belowNo
Explain your serious head or neck injury:
Leave this blank if it does not apply to you.
Have you ever been hospitalized or had a major operation?*

Yes, explain belowNo
Explain your major operation or hospitalization:
Leave this blank if it does not apply to you.
Have you ever had an allergic reaction to Novocain, local or general anesthetics?*

Yes, explain belowNo
Explain your allergic reaction to Novocain, local or general anesthetics:
Leave this blank if it does not apply to you.
Have you had trouble from previous dental care?*

Yes, explain belowNo
Explain any trouble from previous dental care:
Leave this blank if it does not apply to you.
Does your primary doctor recommend a pre-medication for dental visits?*

Yes, explain belowNo
Explain your doctor's recommended pre-medication for dental visits:
Leave this blank if it does not apply to you.
AUTHORIZATION AND RELEASE
I have read and answered the above questions to the best of my knowledge.
Patient/Guardian Signature*
Date*

MonthDayYear
Date
Should be Empty:

MEDICAL AND DENTAL HEALTH HISTORY

AUTHORIZATION AND RELEASE