romanssoltanidentistry.com-ADA Health form

Patient Dental & Medical Health History Information

To our patients: Please know that we may ask follow-up questions to make sure we have all of the information we need in order to treat you.
PATIENT INFORMATION

Last Name First NameMiddle Name
Home Phone
Please enter a valid phone number.
Cell Phone
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
Email Address
example@example.com
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth

MonthDayYear
Date
Gender

MaleFemale
Emergency Contact
Name
Relationship
Phone
Please enter a valid phone number.
If you are completing this form for another person, what is your name and relationship to that person?
Name
Relationship
If executing this form as the patient’s personal representative, I represent and warrant that I have full legal right and authority to consent to the performance of any procedure(s) on this patient. If for any reason I no longer have such legal right and authority, I will immediately notify the practice in writing.
DENTAL HISTORY & SYMPTOMS
What is the reason for your visit today?
Are you currently experiencing any dental pain or discomfort?

YesNo
If yes, where?
When was your last dental exam?

MonthDayYear
Date
What was done at that appointment?
When was the last time you had dental x-rays taken?
Please mark an “X” in the box ONLY if this applies to you.

Is it hard to open your mouth?Does it hurt to chew, bite or swallow?Do your gums bleed when you brush or floss your teeth?Have you ever had periodontal (gum) treatments like scaling and root planing?Do you have, or have you ever had, any sores or growths in your mouth?Do you clench or grind your teeth?Does your jaw click, pop or hurt?Do you have earaches or neck pains?Does dental treatment make you nervous?
Have you ever experienced any of these sleep-related breathing disorders?

Mouth breathingSnoringTrouble breathing during sleep
Have you ever had a serious injury to your head or mouth?

YesNo
If yes, please describe what happened and when it happened
Have you ever had problems with dental treatment in the past?

YesNo
If yes, please describe what happened:
Have you ever had a reaction to, or problem with, dental anesthesia?

YesNo
If yes, please describe what happened
Are you unhappy with your smile?.

YesNo
If yes, why? Please mark all that apply:

The color of your teethThe shape of your teethThe position of your teethOther
MEDICATIONS & OTHER PRODUCTS/SUBSTANCES
Are you taking any blood thinners (such as Coumadin, Warfarin, rivaroxaban (Xarelto®), dabigatran (Pradaxa®), clopidogrel (Plavix®), heparin or aspirin)?.

YesNo?
If yes, what medication are you taking?
Are you taking any medication to treat osteoporosis or Paget’s disease?

YesNo?
If yes, what medication are you taking?
Some commonly-prescribed drugs include alendronate (Fosamax®), risedronate (Actonel®), ibandronate (Boniva®), zolendronate (Reclast®), and denosumab (Prolia®).
Are you taking, or scheduled to take, an IV medication to treat bone pain, hypercalcemia or skeletal complications resulting from Paget’s disease, multiple myeloma or metastatic cancer?

YesNo?
Some commonly-prescribed drugs include denosumab (Xgeva®), pamidronate (Aredia®) or zolendronate (Zometa®).
If yes, what medication are you taking?
How many years have you been taking it?
Are you taking hormonal replacements? ..

YesNo?
Do you use any form of tobacco or nicotine products (cigarettes, cigars, snuff, chew, bidis)?

YesNo?
Do you use vaping products?

YesNo?
How many alcoholic beverages do you have per week?
Do you use controlled substances (drugs), including marijuana, for either medicinal or recreational reasons?

YesNo?
If yes, what substances?
If yes, how often is your use?

DailySeveral times per weekWeeklyOccasionally
Was the substance prescribed by a doctor?

YesNo
If yes, for what reason(s)?
Do you take any other prescriptions and/or over-the-counter medicine(s), vitamins, herbs and/or supplements?.

YesNo?
If yes, please list them here and include information about how much and how often you use each one
WOMEN ONLY: Are you:
Taking birth control pills?

YesNo?
Pregnant? If yes, number of weeks
Nursing? If yes, number of weeks:

Are you allergic to or have you had an allergic reaction to:

Rows	Yes	No	?
Aspirin
Barbiturates, sedatives or sleeping pills
Codeine or other narcotics
Hay fever/seasonal allergies
Iodine
Latex (rubber)
Local anesthetics
Metals
Penicillin or other antibiotics.
Sulfa drugs such as sulfamethoxazole-trimethoprim (Septra, Bactrim), erythromycin-sulfisoxazole, sulfasala-zine (Azulfidine), erythromycinsulfisoxazole (Eryzole, Pediazole) glyburide (Diabeta, Glynase PresTabs), dapsone, sumatriptan (Imitrex), celecoxib (Celebrex), hydrochlorothiazide (Microzide) and furosemide (Lasix)
Other

Please describe any “Yes” answers and include information about your experience.
MEDICAL & SURGICAL HISTORY
Date of last physical exam

MonthDayYear
Date
What is your normal blood pressure (systolic, diastolic)?
Doctor’s Name
Phone

MonthDayYear
Date

Please use an “X” to mark your answers to the following questions

Rows	Yes	No	?
Are you in good physical health?
Are you currently being seen or treated by a physician?
Has a physician or previous dentist recommended that you take antibiotics before having dental work done?
Have you had a serious illness, operation or been hospitalized in the past 5 years?
Have you had any type (either total or partial) of joint replacement surgery (such as for a hip, knee, shoulder, elbow, finger, etc.)?
Have you had a heart valve replacement or heart surgery?
Have you had an organ or bone marrow/stem cell transplant?
Have you traveled internationally within the last 30 days?
Have you had a fever (100.4o F or above) in the last 72 hours?

If you answered yes to any of the above, please explain:
MEDICAL HISTORY SPECIFIC

Please use an “X” to mark your answers to the following questions.
Do you have, or have you been diagnosed with, any of the following conditions?

Heart (Cardiac) Health

Rows	Yes	No	?
Pacemaker/implanted defibrillator
Artificial (prosthetic) heart valve
Previous infective endocarditis
Congenital heart disease (CHD)
Unrepaired, cyanotic CHD
Repaired (completely) in last 6 months
Repaired CHD with residual defects
Arteriosclerosis
Coronary artery disease
Congestive heart failure
Damaged heart valves
Heart attack
Heart murmur/rhythm disorder
Rheumatic heart disease
Stroke

Breathing (Respiratory) Health

Rows	Yes	No	?
Asthma (COPD)
Bronchitis
Emphysema
Sinus trouble
Tuberculosis

Cancer

YesNo?
Type
Date of diagnosis
Chemotherapy
Radiation treatment
Blood (Circulatory) Health
Anemia

YesNo?
Blood transfusion

YesNo?
If yes, date

MonthDayYear
Date
Hemophilia

YesNo?
High or low blood pressure

YesNo?

Brain (Neurological)/Mental Health

Rows	Yes	No	?
Anxiety
Depression
Epilepsy
Mental health disorders
Neurological disorders
Post-traumatic stress disorder
Traumatic brain injury or concussio

Autoimmune Disease
AIDS or HIV Infection

YesNo?
Lupus

YesNo?
Digestive Health
Gastrointestinal disease

YesNo?
Gastrointestinal disease

YesNo?
G.E. reflux/persistent heartburn (GERD).

YesNo?
Stomach ulcers

YesNo?
Eye (Vision) Health
Glaucoma

YesNo?
Other
Arthritis

YesNo?
Chronic pain

YesNo?
Diabetes (type I or II)

YesNo?
Eating disorder

YesNo?
Frequent infections

YesNo?
Type of infection

YesNo?
Hepatitis, jaundice or liver disease

YesNo?
Immune deficiency

YesNo?
Kidney problems

YesNo?
Malnutrition

YesNo?
Osteoporosis

YesNo?
Rheumatoid arthritis

YesNo?
Sexually transmitted infection (STI)

YesNo?
Thyroid problems

YesNo?
Do you have any disease, condition, or problem that’s not listed here? If so, please explain
MEDICAL SYMPTOMS/GENERAL

Please use an “X” to mark your answers to the following questions.

In the past 30 days, have you:

Rows	Yes	No	?
Had pain or tightness in the chest?
Coughed up blood or had a cough that lasted longer than 3 weeks?
Been exposed to anyone with tuberculosis?
Had a rapid or irregular heart beat?
Found it hard to catch your breath?
Had a high fever (greater than 101.5˚F) for no reason?
Noticed a change in your vision?
fainted for no reason?
Experienced vomiting, diarrhea, chills, night sweats or bleeding?
Had migraines or severe headaches?

NOTE: It’s important for both the doctor and patient to talk honestly about the patient’s health before dental treatment starts

I have answered the above questions completely, accurately and to the best of my ability
Signature of Patient/Legal Guardian

Clear
Date

MonthDayYear
Date
Should be Empty:

Patient Dental & Medical Health History Information

If you are completing this form for another person, what is your name and relationship to that person?

DENTAL HISTORY & SYMPTOMS

MEDICATIONS & OTHER PRODUCTS/SUBSTANCES

WOMEN ONLY: Are you:

MEDICAL & SURGICAL HISTORY

MEDICAL HISTORY SPECIFIC

Blood (Circulatory) Health

Autoimmune Disease

Digestive Health

Eye (Vision) Health

Other

MEDICAL SYMPTOMS/GENERAL

NOTE: It’s important for both the doctor and patient to talk honestly about the patient’s health before dental treatment starts