Download Medical Dental History

Garner Orthodontics
Medical and Dental History
Patient Name: _________________________________________ Date: _________________________
Dentist’s Name: ______________________________ Date of last exam/cleaning: ________________
PLEASE MARK THE ITEM/ITEMS YOU HAVE A HISTORY OF:
□ Birth Problems
□ Lupus
□ Speech Problems
□ Learning Disabilities
□ Tonsils/Adenoid Problems
□ Attention Deficit Disorder
□ Diabetes
□ Arthritis
□ Cancer
□ Bleeding or Hemophilia
□ Blood Transfusion
□ Hepatitis
□ AIDS or HIV+
□ Tuberculosis
□ Venereal Disease
□ High Blood Pressure
□ Asthma
□ Sleep Apnea
□ Osteoporosis
□ Mononucleosis
□ Heart Murmur
□ Chronic Cough
□ Thyroid Condition
□ Hearing Loss
□ Growth Problems
□ Rheumatic Fever
□ Anemia
□ Cerebral Palsy
□ Vision Problems
□ Radiation or Chemotherapy
□ Smoking
□ Smokeless Tobacco
□ Drug or Alcohol Use
□ Hypoglycemia
□ Epilepsy or Seizures
□ Cleft Lip or Cleft Palate
□ Liver Disease
□ Kidney Disease
□ Emotional or Behavior Problems
□ Skin Problems
□ Psychotherapy
□ Fainting
PLEASE MARK ALL THAT APPLY AND PROVIDE AN EXPLANATION:
□ Allergies to Latex, Metal or Medications: _________________________________________________
□ Frequent Headaches: _________________________________________________________________
□ Surgery: ___________________________________________________________________________
□ Jaw popping, clicking or locking: ________________________________________________________
□ Under care of dentist, physician or chiropractor: ___________________________________________
□ Pain in face, jaw or back: ______________________________________________________________
□ Car accident: ________________________________________________________________________
□ Grinding or clenching teeth: ____________________________________________________________
□ Head, neck or face injury: ______________________________________________________________
□ Premedication required for dental work: __________________________________________________
LIST ALL MEDICATIONS YOU ARE TAKING, INCLUDING NAME AND REASON FOR USE:
_____________________________________________________________________________________
_____________________________________________________________________________________
I certify that the above information is correct.
SIGNATURE: ____________________________________
Printed Name: __________________________________
SIGNATURE OF DOCTOR: __________________________
DATE: ______________________________
Relationship to patient: ________________
DATE: _______________________________