berlindentalct.com - Patient Dental and Medical Health History

Patient Dental and Medical Health History Information
To the 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
Name:

First NameMiddle NameLast Name
Home Phone:
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone:
Please enter a valid phone number.Format: (000) 000-0000.
Work Phone:
Please enter a valid phone number.Format: (000) 000-0000.
Email Address:
example@example.com
Mailing Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth:

MonthDayYear
Date
Gender:
Occupation:
Emergency Contact
Name
Name
Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
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?
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 "Yes" or "No" in the box ONLY if this applies to you.

Rows	Yes	No
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?

Mouth breathingSnoringTrouble breathing during sleep
YesNo
If yes, please describe what happened and when it happened:
YesNo
If yes, please describe what happened:
YesNo
If yes, please describe what happened:
YesNo
The color of your teethThe shape of your teethThe position of your teethOther
MEDICATIONS & OTHER PRODUCT SUBSTANCES
YesNo
If yes, what medication are you taking?
YesNo
YesNo
If yes, what medication are you taking?
YesNo
YesNo
If yes, what medication are you taking?
How many years have you been taking it?
YesNo
YesNo
YesNo
How many alcoholic beverages do you have per week?
YesNo
If yes, what substances?
DailySeveral times per weekWeeklyOccasionally
YesNo
If yes, for what reason(s)?
YesNo
If yes, please list them here and include information about how much and how often you use each one.
WOMEN ONLY: Are you:
YesNo
YesNo
If yes, number of weeks:
YesNo
If yes, number of weeks:

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...

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 (100.4°F or above) in the last 72 hours?

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

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

Patient Dental and Medical Health History Information

Rows	Yes	No
Gastrointestinal disease
GE. reflux/persistent heartburn (GERD)
Stomach ulcers

Rows	Yes	No
Arthritis
Chronic pain
Diabetes (type I or II)
Eating disorder
Frequent infections
Hepatitis, jaundice or liver disease
Immune deficiency
Kidney problems
Malnutrition
Osteoporosis
Rheumatoid arthritis
Sexually transmitted infection (STI)
Thyroid problems

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?.