Patient Medical History Form

Patient Medical History

(HIPAA Compliant
Patient Name *

First Name Last Name
Patient DOB *

Month Day Year
Patient Medical History
Please list any drug, food, material allergies, etc. *
Have you ever had (Please check all that apply) *

Anemia Arthritis Asthma Bleeding Disorders Cancer Diabetes Emotional Disorder Epilepsy Seizures Excessive Bleeding Eye Problems Fainting Spells Heart Disease Hepatitis Kidney Disease Learning Disability Lung Disease Mitro Value Prolapse Mononucleosis Neurological Disorders Pneumonia Respiratory Problems Rheumatic Fever Sleep Apnea Thyroid Problems Tuberculosis Ulcer Disease Ulcerative Colitis Venereal Disease None of the Above
Other illnesses:
Please list any Operations and Dates of Each
Please list your Current Medications
Is the patient pregnant? *

Yes No I don't know
Is the patient in good health? *

Yes No
Does the patient have a dentist? *

Yes No
Does the patient have a primary care physician? *

Yes No
Does the patient have any of the following conditions of the jaw? *

Clicking Popping Jaw locking Jaw soreness or pain None of the above
Does the patient grind or clench his/her teeth? *

Yes No I don't know
Does the patient have frequent headaches, nose bleeds or cold sores? *

Yes No I don't know
Does the patient have bleeding gum? *

Yes No I don't know
Has the patient had any falls or accidents involving the teeth? List below
Should be Empty: