Medical History
Personal / Physician Information
Do you have a personal physician?
Yes
No
Physician’s Name:
Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Date of last visit:
-
Month
-
Day
Year
Date
General Health
Your current physical health is:
Good
Fair
Poor
Are you currently under the care of a physician?
Yes
No
Do you smoke or use tobacco in any form?
Yes
No
Have you had any metal rods, pins or implants?
Yes
No
Are you taking any prescription/over-the-counter drugs?
Yes
No
Please list each one:
Have you ever taken Fosamax or any bisphosphonate?
Yes
No
Have you ever taken Phen-Fen (Redux or Pondimin)?
Yes
No
Women Only
Are you taking birth control pills?
Yes
No
Are you pregnant?
Yes
No
Week #
Are you nursing?
Yes
No
Have you ever had any of the following diseases or medical problems?
Abnormal Bleeding / Hemophilia
Yes
No
AIDS
Yes
No
Alcohol / Drug Abuse
Yes
No
Anemia
Yes
No
Arthritis
Yes
No
Artificial Bones/Joints/Valves
Yes
No
Asthma
Yes
No
Blood Transfusion
Yes
No
Cancer/Chemotherapy
Yes
No
Colitis
Yes
No
Congenital Heart Defect
Yes
No
Diabetes
Yes
No
Difficulty Breathing
Yes
No
Emphysema
Yes
No
Epilepsy
Yes
No
Fainting Spells
Yes
No
Frequent Headaches
Yes
No
Glaucoma
Yes
No
Hayfever
Yes
No
Heart Attack/Surgery
Yes
No
Heart Murmur
Yes
No
Hepatitis
Yes
No
Herpes/Fever Blisters
Yes
No
High Blood Pressure
Yes
No
HIV
Yes
No
Hospitalized for Any Reason
Yes
No
Kidney Problems
Yes
No
Liver Disease
Yes
No
Low Blood Pressure
Yes
No
Lupus
Yes
No
Mitral Valve Prolapse
Yes
No
Pacemaker
Yes
No
Radiation Treatment
Yes
No
Rheumatic/Scarlet Fever
Yes
No
Seizures
Yes
No
Shingles
Yes
No
Sickle Cell Disease/Traits
Yes
No
Sinus Problems
Yes
No
Stroke
Yes
No
Thyroid Problems
Yes
No
Tuberculosis (TB)
Yes
No
Ulcers
Yes
No
Venereal Disease
Yes
No
Please list any serious medical condition(s) you have ever had:
Allergies
Are you allergic to any of the following?
Allergy
Yes
No
Aspirin
Yes
No
Codeine
Yes
No
Dental Anesthetics
Yes
No
Erythromycin
Yes
No
Jewelry/Metals
Yes
No
Allergy
Yes
No
Latex
Yes
No
Penicillin
Yes
No
Tetracycline
Yes
No
Other
Yes
No
List any other drug/material allergies:
Dental / Orthodontic History
Have you ever had or been evaluated for orthodontic treatment?
Yes
No
Have you ever had a serious/difficult problem associated with previous dental work?
Yes
No
Do you now or have you ever experienced pain/discomfort in your jaw joint (TMJ/TMD)?
Yes
No
Your current dental health is:
Good
Fair
Poor
Do you still have wisdom teeth?
Yes
No
Have you ever had an injury to your:
Mouth
Teeth
Chin
Do you have any speech problems?
Yes
No
Do you breathe through your mouth?
While Awake
While Asleep
Do you have any missing or extra permanent teeth?
Yes
No
Do you like your smile?
Yes
No
If not, what would you change?
Consent
I understand that the information I have given today is correct to the best of my knowledge. I understand that this information will be held in the strictest confidence and that it is my responsibility to inform this office of any changes in my medical status.
I authorize the dental staff to perform any necessary dental services that I may need during diagnosis andtreatment, with my informed consent.
Signature
*
Date
*
-
Month
-
Day
Year
Medical History Update
Has there been any change in your health status since your last visit?
Yes
No
If yes, please explain:
Signature
*
Date
*
-
Month
-
Day
Year
Has there been any change in your health status since your last visit?
Yes
No
If yes, please explain:
Signature
*
Date
*
-
Month
-
Day
Year
Submit
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