Download Dental Medical History Form - VanderLaan Family Dentistry

Patient Name: ________________________________________ Today’s date: __________________
Patient Dental History (Adult)
Date of last Dental visit: ________________________
How often do you brush? __________________________________ Floss? _____________________________
Are you having any discomfort at this time?............................................................................................. □Yes
Are you satisfied with the appearance of your teeth and smile?.............................................................. □Yes
□No
□No
□No
Have you had any issues associated with previous dental treatment?..................................................... □Yes
If “Yes”, explain:____________________________________________________________________________
Have you ever been treated for periodontal (gum) disease?.…………………………………………………………………□Yes
Have you ever had any teeth extracted?................................................................................................... □Yes
□Slightly
Does Dental treatment make you nervous?
□Moderately
□Extremely
□No
□No
□No
Please select if the following symptoms or issues apply:
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Bleeding/Sore gums
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Difficulty opening or closing
mouth
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Frequent cold sores
Burning tongue or lips
Swelling or lump in mouth
Biting lips or cheeks
Clicking or popping jaw joint
Canker sores
Loose tooth/teeth
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Sensitivity to hot
Sensitivity to cold
Sensitivity to sweets
Pain when biting
Clinching or grinding
Patient Medical History (Adult)
Physician: __________________________ Phone #:______________________________Date of Last Exam: _____________
Have you been hospitalized in the last five years? □Yes □No
If “Yes”, reason: ________________________________________________________________________________________
Do you have any allergies? □Yes
□Penicillin □Codeine □Latex
□No (If so, please select)
□Local Anesthetics □Sulfa Drugs □Aspirin □Jewelry/Metals □Other (list):
_____________________________________________________________________________________________________
Are you currently on any prescription or over the counter medications, vitamins, nutritional or herbal supplements? □Yes □No
(If “Yes”, please list below) ________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
(over)
Circle Y/N for all that apply to you and your medical history:
Y / N Are you/ have you ever taken medication for
Osteoporosis?
Y / N Use or have used Tobacco products?
Y / N Need antibiotic pre-medication prior to dental
work?
Y / N Partial or complete joint replacement?
Y / N Subject to prolonged bleeding?
Y / N Undergone Radiation or Chemotherapy?
Y / N Excessive thirst and/or urination?
Y / N Have you ever required a blood transfusion?
Y / N Recent unusual weight loss?
Y / N (Women) Currently pregnant? ______(Weeks?)
Y / N (Women) Are you taking birth control
medications?
Y / N (Women) Are you taking Hormone
Replacement Therapy?
Y / N (Women) Currently Nursing?
Y / N Family history of Diabetes?
Do you have / have you had / have you received treatment for any of the following diseases or conditions?
Please select all that apply:
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Anemia
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Diabetes (type____)(AIC____)
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Sexually Transmitted Diseases (If
so, what disease?) _____________
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Ulcers/Stomach Issues
Hemophilia
Blood Disorder
Seizures
Epilepsy
Liver Disease
Kidney Disease
Asthma
Sinus Issues
Seasonal Allergies
Hives
Cancer(type____________
_______________________)
Rheumatic Fever
Stroke
AIDS/HIV Infection
Neck/ Back Problems
Arthritis
Osteoporosis
Artificial Joint (Joint Replacement)
Hepatitis (type____)
Tuberculosis
Scarlet Fever
Respiratory Problems
Emphysema
Psychiatric or Emotional Disorder
Eating Disorder
Long-term Steroid Treatment
Dementia
Thyroid Issues
Heart Attack
Heart Disease
Do you have any other medical or health condition which is not listed?
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High Blood Pressure
Low Blood Pressure
Other Heart Issues
Chest Pains
Pacemaker
Mitral Valve Prolapse
Defective Valve
Repaired Valve
Replaced Heart Valve
Congestive Heart Failure
Rheumatic Heart Disease
Congenital Heart Disease
Heart Murmur
Fainting Spells
Congenital Heart Defect
Bypass Surgery
Stents
Other Cardiovascular Issues
□Yes □No
(If “Yes”, please list)
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To the best of my knowledge, all of the preceding answers are true and correct. If there are any changes in
my health or medications, I will inform Dr. VanderLaan at my next appointment.
Signature of Patient or Guardian
Date