Dental Patient - Medical History

Medical History
Name

First NameLast Name
Physician's Name
Date of last visit

MonthDayYear
Date
YesNo
If No, explain
YesNo
If yes, explain
YesNoNot Applicable
YesNo
YesNo
Medical History Information

Select Yes or No if you have had any of the following:
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
If Yes, Describe:
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
If Select Yes Explain:
YesNo
YesNo
YesNo
YesNo
YesNo
Type:
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNoOther
YesNo
If Yes Explain :
Dental History
Sensitive Teeth to ColdSensitive Teeth to HotSensitive Teeth to SweetsTeeth Grinding / ClenchingTeeth Pain to BitingTMJ PainDry MouthHeadachesJaw PainDifficulty Opening MouthCanker and Cold SoresOther
YesNo
If Selected Yes Explain:
Medications
NONEHigh Blood PressureBlood ThinnerAntibioticsAspirinPain MedicationBisphosphonate (Fosamax)
List if you have other medications ?
Pharmacy
Allergies
Aspirin/ IbuprofenCodeineVicodin/HydrocodoneSulfa DrugsValiumLocal AnestheticMetalsPenicillin/AmoxicillinErythromycinClindamycinPercodanFoodLatexBarbiturates (Sleeping Pills)NONEOther
Please List the Metals:
MEDICAL HISTORY UPDATE
(To be filled in at future appointments)
Date

MonthDayYear
Date
Health Changes
Patient's Initials
Dentist Initials
Date

MonthDayYear
Date
Health Changes
Patient's Initials
Dentist Initials
Date

MonthDayYear
Date
Health Changes
Patient's Initials
Dentist Initials
Date

MonthDayYear
Date
Health Changes
Patient's Initials
Dentist Initials
SIGNATURE
I certify that I have read and understand this form. To the best of my knowledge, I have answered every question completely and accurately. I will inform my dentist of any change in my health and/or medication. Further, I will not hold my dentist, or any member of his staff, responsible for any errors or omissions that I may have made in the completion of this form.
Signature of Patient

Clear
Date

MonthDayYear
Date
Should be Empty:

Medical History

Medical History Information

Dental History

Medications

Allergies

MEDICAL HISTORY UPDATE

SIGNATURE