Medical History Form
Patient Name
*
MR .
MISS.
MRS.
MS
DR.
Title
First Name
Last Name
Gender
*
Please Select
Male
Female
Birth Date
*
Please select a month
January
February
March
April
May
June
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November
December
Month
Please select a day
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31
Day
Please select a year
2024
2023
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Year
01. Are you seeing a physician at the present time for the treatment of a recent or ongoing medical condition?
*
YES
NO
If yes, explain
*
2. Have you been hospitalized within the last year?
*
YES
NO
If yes, explain
*
3. Have you had a serious illness or operation within the last year?
*
YES
NO
If yes, explain
*
4. Have you ever had any serious medical trouble associated with any dental experience?
*
YES
NO
If yes, explain
*
5. Have you ever been advised to take antibiotics (like penicillin, etc.) before a dental appointment?
*
YES
NO
If yes, explain
*
Do you now or have you had any of the following diseases or problems?
Cardiovascular Disease
*
YES
NO
Heart disease
Heart murmur
Coronary bypass
Angina
Heart Attack
Hardening of the arteries
High blood pressure
Mitral valve prolapse
Congestive heart failure
Stroke
If Select "Heart Attack" When?
-
Month
-
Day
Year
Date
If Select "Stroke" When?
-
Month
-
Day
Year
Date
Rheumatic fever or rheumatic heart disease
*
YES
NO
Infective endocarditis
*
YES
NO
Congenital heart defects
*
YES
NO
Prosthetic (artificial) heart valves
*
YES
NO
Pacemaker?
*
YES
NO
If yes, date of placement
-
Month
-
Day
Year
Date
High cholesterol
*
YES
NO
Shortness of breath?
*
YES
NO
Do your ankles swell?
*
YES
NO
Do you have chest pain upon exertion?
*
YES
NO
Abnormal bleeding or extended clotting time
*
YES
NO
Frequent or unexpected nose bleeds
*
YES
NO
Have you ever required a blood transfusion?
*
YES
NO
If yes, what was the date of the transfusion?
-
Month
-
Day
Year
Date
Are you HIV positive?
*
YES
NO
Do you have any reason to suspect that you have been exposed to the HIV virus
*
YES
NO
Hepatitis?
*
YES
NO
Select
*
Type A
Type B
Type C
Other
Non-Specific Type
Not Sure
Diabetes?
*
YES
NO
If yes, do you require insulin?
Type and Dose
Do you have an artificial joint?
*
YES
NO
If yes, which joint(s)?
Have you ever had Tuberculosis (TB)?
*
YES
NO
Have you ever had a TB test?
*
YES
NO
Do you have a cough that has lasted more than 3 weeks?
*
YES
NO
Do you ever cough up blood?
*
YES
NO
Have you tested positive for Covid-19
*
YES
NO
Cancer?
*
YES
NO
If yes, type of cancer and date diagnosed
Oncologist name
Cancer treatments (chemotherapy or radiation & cycle)
Last blood count
Central line?
*
YES
NO
SELECT ANY THAT APPLY
Heart Disease
Heart Failure
Angina
Anemia
Leukemia
Hemophilia
Autoimmune Disease
Lupus, Sickle Cell Anemia
HIV / AIDS
Lung Disease
Chronic/ Recurring
Sinus Problems
Persistent cough
Emphysema
Bronchitis
Pneumonia
Asthma/ Hay Fever
Ulcers
Glaucoma
Hearing Disorders
Cerebral Palsy
Immunocompromised
Acid Reflux
Jaundice or Liver Disease
Kidney Disease
Syphilis or Gonorrhea
Sexually Transmitted Disease
Arthritis
Inflammatory Rheumatism
Joint Replacement
Osteoporosis
Parkinson’s Disease
Epilepsy or Other Seizures
Alzheimer’s Disease
Paralysis
Multiple Sclerosis
Organ transplant
Depression
Anxiety
Psychiatric Treatment
Thyroid Disease (Hypothyroidism, Hyperthyroidism)
Ulcers
Cortisone treatment
Other
If "Other" Please Explain
When was your last complete physical exam with your medical doctor, including blood tests?
-
Month
-
Day
Year
Date
If you are currently taking these medications – prescribed, over-the-counter, herbal. Please list name of drug, dose and frequency.
Antibiotics
*
YES
NO
Antidepressants (Prozac, Zoloft, etc.)
*
YES
NO
Antihistamines
*
YES
NO
Blood Pressure Medicine
*
YES
NO
Blood Thinners
*
YES
NO
Cortisone (Prednisone, etc.)
*
YES
NO
Cholesterol Medication
*
YES
NO
Decongestants
*
YES
NO
Diuretics (water pills)
*
YES
NO
Hormones (birth control pills, estrogen)
*
YES
NO
Inhalants (puffer)
*
YES
NO
Insulin
*
YES
NO
Medicine for Heart Problems
*
YES
NO
Muscle Relaxants
*
YES
NO
Nitroglycerine
*
YES
NO
Pain Medicine (Aspirin, Advil, Tylenol, etc)
*
YES
NO
Prescription Pain Medication
*
YES
NO
Sleeping Pills
*
YES
NO
Thyroid Medicine
*
YES
NO
Tranquilizers
*
YES
NO
Vitamins
*
YES
NO
CBD
*
YES
NO
List all names of drugs & dose
Are you ALLERGIC to any of the following medications (do you get hives, a rash, have trouble breathing, etc.):
Antibiotics (penicillin, tetracycline, etc .)
*
YES
NO
Local or topical Dental Anesthetics (novacaine)
*
YES
NO
Codeine
*
YES
NO
Aspirin
*
YES
NO
Barbituates or Sedatives
*
YES
NO
Tranquilizers
*
YES
NO
Food (Dairy)
*
YES
NO
Cortisone (Steroids)
*
YES
NO
Latex
*
YES
NO
Other
*
YES
NO
If Other, Please Explain
*
Do you now or have you ever smoked?
*
YES
NO
Please Select
*
Cigarettes
Pipe
Cigar
Vape
Other
If you currently smoke, how many/much per day?
If you have smoked in the past but no longer smoke, when did you quit?
Do you smoke marijuana / cannabis use?
*
YES
NO
How often?
Do you chew tobacco?
*
Yes
No
If yes, how often?
Do you drink alcohol?
*
Yes
No
If yes, how much?
Are you currently on hormone replacement therapy?
*
Yes
No
Have you ever had an adverse reaction like nausea, dizziness, or feeling “spacey” with any drug or medication?
*
Yes
No
Do you have any disease, condition or problem not previously listed that you feel we should know about?
*
Yes
No
WOMEN
Are you currently pregnant?
*
Yes
No
Expected delivery date
*
-
Month
-
Day
Year
Date
Dental History
Date of last dental/ dental hygiene visit?
-
Month
-
Day
Year
Date
What dental conditions concern you at the present time?
What care did you receive at the last dental visit?
How often do you receive dental treatment or dentalhygiene care?
Do you require complete mouth care or emergency treatment?
Are you under the care of a dental specialist? (Orthodontist, Endodontist, Prosthodontist, Periodontist)
*
Yes
No
Type?
*
Have you ever had a thorough exam of your mouth including a complete set of radiographs (16-20 films)of your jaws and teeth?
*
Yes
No
When?
*
Have you had x-rays in the past two years?
*
Yes
No
Have you had any dental problems within the last year with your teeth, gums, jaw, chewing?
*
Yes
No
In order that we may be sensitive to your dental needs, please tell us of any unpleasant experiences you may have had related to oral care.
Patient’s / Parent / Guardian Signature
*
Patient’s / Parent / Guardian Name
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
Date
Submit
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