Patient Medical History
(HIPAA Compliant
Patient Name
*
First Name
Last Name
Patient DOB
*
January
February
March
April
May
June
July
August
September
October
November
December
Month
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31
Day
2020
2019
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1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
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
Is the patient under Dental care at the moment?
*
Yes
No
Is the patient under Medical care at the moment?
*
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
Submit
Should be Empty: