PATIENT MEDICAL HISTORY
PATIENT NAME
TODAY'S DATE
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Month
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Date
HOME ADDRESS
DATE OF BIRTH
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Month
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SOCIAL SECURITY NUMBER
OCCUPATION
HOME PHONE
Format: (000) 000-0000.
EMAIL
example@example.com
CELL PHONE
Format: (000) 000-0000.
DENTAL HISTORY
REASON FOR TODAY'S VISIT
DATE OF LAST DENTAL EXAM AND CLEANING
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Month
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PLEASE CIRCLE ANY CONDITIONS THAT APPLY:
BAD BREATH
BLEEDING GUMS
FOOD COLLECTION BETWEEN TEETH
SORES OR GROWTHS IN YOUR MOUTH
LOOSE TEETH OR BROKEN FILLINGS
PERIODONTAL TREATMENT
SENSITIVITY TO COLD
SENSITIVITY TO HOT
SENSITIVITY TO SWEETS
SENSITIVITY WHEN BITING
GRINDING TEETH
CLICKING OR POPPING JAW
HOW OFTEN DO YOU FLOSS?
HOW OFTEN DO YOU BRUSH?
PATIENT MEDICAL HISTORY
PHYSICIAN
OFFICE PHONE
Format: (000) 000-0000.
DATE OF LAST EXAM
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ARE YOU UNDER MEDICAL TREATMENT NOW?
YES
NO
IF YES, WHAT FOR?
HAVE YOU EVER BEEN HOSPITALIZED FOR ANY SURGICAL OPERATION OR SERIOUS ILLNESS
YES
NO
IF YES, PLEASE LIST:
PLEASE CIRCLE ANY DRUG ALLERGIES
ASPIRIN
LATEX
PENICILLIN
SULFA
CODEINE
BARBITURATES
LOCAL ANESTHETIC
Other
HAVE YOU EVER TAKEN ANY OF THE GROUP OF DRUGS COLLECTIVELY REFERRED TO AS PISPHOSPHONATES? (THIS WOULD INCLUDE DRUGS FOR OSTEOPOROSIS SUCH AS SAMAX, BONIVA, ACTONEL, ATELVIA, AND RECLAST)
YES
NO
DO YOU TAKE ANY BLOOD THINNERS? INCLUDING DAILY ASPIRIN?
YES
NO
PLEASE SELECT IF YOU HAVE OR HAVE HAD ANY OF THE FOLLOWNG:
HIGH BLOOD PRESSURE
HEART ATTACK
ARTIFICIAL HEART VALVES
DIABETES TYPE 1 OR TYPE 2
HEART DISEASE
CARDIAC PACEMAKER
HEART MURMUR
ANGINA
CHEST PAINS
STROKE
LOW BLOOD PRESSURE
EMPHYSEMA/COPD
HAY FEVER/ALLERGIES
TUBERCULOSIS
PERSISTENT COUGH
ASTHMA
ANEMIA
CANCER
RADIATION THERAPY
BLOOD DISEASE
CHEMOTHERAPY
LEUKEMIA
STEROID TREATMENT
KIDNEY DISEASES
LIVER DISEASE
HEPATITIS/JAUNDICE
SEXUALLY TRANSMITTED DISEASE
AIDS OR HIV INFECTION
THYROID PROBLEM
ARTHRITIS
JOINT REPLACEMENT/IMPLANT
STOMACH TROUBLES/ULCERS
GLAUCOMA
CATARACTS
EPILEPSY/SEIZURES
AUTISM/SPECTRUM DISORDERS
Other
PLEASE LIST MEDICATIONS YOU ARE CURRENTLY TAKING INCLUDING VITAMINS AND HERBAL SUPPLEMENTS
IN ORDER TO SERVE YOU BETTER DURING ORAL CANCER SCREENINGS, PLEASE ANSWER THE FOLLOWING:
DO YOU USE NICOTINE PRODUCTS IN THE FORM OF VAPING OR E-CIGARETTES
YES
NO
DO YOU USE TOBACCO?
YES
NO
DO YOU DRINK ALCOHOL?
YES
NO
DO YOU USE COCAINE OR OTHER DRUGS?
YES
NO
WOMEN ONLY:
ARE YOU PREGNANT OR DO YOU THINK YOU MAY BE PREGNANT?
YES
NO
ARE YOU NURSING?
YES
NO
ARE YOU TAKING BIRTH CONTROL?
YES
NO
Signature
DATE
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