statonfamilydentistry.com - Medical History Form

MEDICAL HISTORY
PATIENT NAME
Birth Date

MonthDayYear
Date
Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions.
Are you under a physician's care now?

YesNo
If yes, please explain:
Have you ever been hospitalized or had a major operation?

YesNo
If yes, please explain:
Have you ever had a serious head or neck injury?

YesNo
If yes, please explain:
Are you taking any medications, pills, or drugs?

YesNo
If yes, please explain:
Do you need to pre-medicate?

YesNo
If yes, please explain:
Do you take, or have you taken, Phen-Fen or Redux?

YesNo
Are you on a special diet?

YesNo
Do you use tobacco?

YesNo
Do you use controlled substances?

YesNo
Women:
Are you Pregnant/Trying to get pregnant?

YesNo
Taking oral contraceptives?

YesNo
Nursing?

YesNo
Are you allergic to any of the following?

AspirinPenicillinCodeineAcrylicMetalLatexLocal AnestheticsOther

Do you have, or have you had, any of the following?

Have you ever had any serious illness not listed above?

YesNo
If yes, please explain:
Comments:
To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in medical status.
SIGNATURE OF PATIENT, PARENT, or GUARDIAN
Date

MonthDayYear
Date

Rows	Yes	No
1. Unhappy with the appearance of your teeth
2. Unfavorable dental experiences
3. Dental fears
4. Problems with effectiveness or bad reaction to dental anesthetic
5. Orthodontic treatment (braces) when?
6. Periodontal (gum) treatment, when?
7. Bleeding gums
8. Avoid brushing any part of your mouth
9. Part of your mouth is sensitive to temperature
10. Sore teeth
11. A burning sensation in your mouth
12. Difficulty swallowing
13. An unpleasant taste or odor in your mouth
14. Dry mouth, throat, and or eyes
15. Jaw problems (temporomandibular joint)
16. Difficulty opening your mouth widely
17. Stiff neck muscles
18. Awaken with an awareness of your teeth or jaws
19. Tension headaches
20. Clench or grind your teeth
21. Jaw clicking or popping
22. Lost any teeth
23. Do you sweat or tremble a lot during examination

MEDICAL HISTORY