Medical History

Hart Family Dentistry

Eaglesoft Medical History with Sleep Questions

Patient Name:

Birth Date:

Date

Date Created:

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?

If yes

Have you ever been hospitalized or had a major operation?

If yes

Have you ever had a serious head or neck injury?

If yes

Are you taking any medications, pills, or drugs?

If yes

Do you take, or have you taken, Phen-Fen or Redux?

If yes

Have you ever taken Fosamax, Boniva, Actoned or any other medications containing bisphosphonates?

If yes

Are you on a special diet?

Do you use tobacco

Women: Are you...

Are you allergic to any of the following?

Do you use controlled substances?

If yes

Specify

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

Have you ever had any serious illness not listed above?

If yes

We care about your health so we we will be evaluating how easily air flows through your mouth and nose without blockages. Blockages can cause obstructive sleep apnea, a serious medical condition.

Please answer the following questions:

Do you snore or have you been told you snore?

Do you snore every night?

Has your partner had to move to another room during the night?

Do you doze off unintentionally during the day?

Do you often awaken feeling tired?

Do you have problems concentrating for long periods of time?

Do you grind or clench your teeth in your sleep?

Have you ever been treated for snoring, a sleep disorder, or sleep apnea?

Do you snore only when lying on your back?

Have you ever been told you stop breathing or gasp during sleep?

Are you currently or have you been treated for high blood pressure?

Do you fall asleep when driving?

Do you often awaken with a headache?

Are you having accidents on the job or at home?

Do you suspect you have sleep apnea?

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.

Type a question

Date