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Download Patient Medical/Dental History
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MEDICAL HISTORY Patient Name: Date: Please check Yes or No for the following questions Are you in good health now? Y N Are you under the care of a physician? Y N If yes, why Do you have history of rheumatic heart disease or heart murmur? Y N Do you have an artificial joint? Y N Have you ever had excessive bleeding following a dental procedure? Y N Do you use tobacco in any form? Y N If so, how much? (Lady) Are you pregnant? Y N If so, please provides your due date Are you breast-feeding? Y N Please list all allergies – Drugs, Foods, and Environment Please check Yes or No for the following questions Y N Y N Y Eruption (rash) hives Asthma/hay fever Back or neck problems Glaucoma Loss of Hearing Persistent cough or sore throat Difficulty breathing while laying down Arthritis/rheumatism Hepatitis Ringing in ears Frequent nosebleeds Diabetes Thyroid condition/goiter Ulcers Kidney disease Sinus problems Stroke Chest pain/discomfort Heart attack/trouble Venereal disease Radiation therapy Headaches Convulsions/epilepsy Shortness of breath High blood pressure Tumors or growths Cancer Fainting Psychiatric treatment Congenital heart disease Artificial heart valve A.I.D.S. H.I.V. positive Tuberculosis Emphysema Pacemaker Heart surgery Other Have you ever had a surgery? Y N N - If yes, please provide date and type of surgery Names of all medications you are taking and purpose: Have you ever had an injury to the head, jaw or mouth? Y N Does dental treatment make you nervous? No Mildly Moderately Extremely If you could enhance anything about your smile, what would it be? Please add any comments that you feel will assist our team in our concern for your treatment. I understand the above information is necessary to provide me with dental care in a safe and efficient manner. I have answered all questions to the best of my knowledge. Should further information be needed, you have my permission to ask the respective health care provider or agency, which may release such information to you. I will notify the doctor of any change in my health or medication. Patient/Guardian Signature Check the box to sign Date:
