PATIENT MEDICAL HISTORY

PATIENT MEDICAL HISTORY
PATIENT NAME
TODAY'S DATE

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Date
HOME ADDRESS
DATE OF BIRTH

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Date
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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Date
BAD BREATHBLEEDING GUMSFOOD COLLECTION BETWEEN TEETHSORES OR GROWTHS IN YOUR MOUTHLOOSE TEETH OR BROKEN FILLINGSPERIODONTAL TREATMENTSENSITIVITY TO COLDSENSITIVITY TO HOTSENSITIVITY TO SWEETSSENSITIVITY WHEN BITINGGRINDING TEETHCLICKING 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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Date
YESNO
IF YES, WHAT FOR?
YESNO
IF YES, PLEASE LIST:
ASPIRINLATEXPENICILLINSULFACODEINEBARBITURATESLOCAL ANESTHETICOther
YESNO
YESNO
HIGH BLOOD PRESSUREHEART ATTACKARTIFICIAL HEART VALVESDIABETES TYPE 1 OR TYPE 2HEART DISEASECARDIAC PACEMAKERHEART MURMURANGINACHEST PAINSSTROKELOW BLOOD PRESSUREEMPHYSEMA/COPDHAY FEVER/ALLERGIESTUBERCULOSISPERSISTENT COUGHASTHMAANEMIACANCERRADIATION THERAPYBLOOD DISEASECHEMOTHERAPYLEUKEMIASTEROID TREATMENTKIDNEY DISEASESLIVER DISEASEHEPATITIS/JAUNDICESEXUALLY TRANSMITTED DISEASEAIDS OR HIV INFECTIONTHYROID PROBLEMARTHRITISJOINT REPLACEMENT/IMPLANTSTOMACH TROUBLES/ULCERSGLAUCOMACATARACTSEPILEPSY/SEIZURESAUTISM/SPECTRUM DISORDERSOther
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:
YESNO
YESNO
YESNO
YESNO
WOMEN ONLY:
YESNO
YESNO
YESNO
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DATE

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Date
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PATIENT MEDICAL HISTORY

DENTAL HISTORY

PATIENT MEDICAL HISTORY

WOMEN ONLY: