Skip to content
Patients Medical History
Dentalcare
2023-09-14T08:21:49+00:00
Download Form
Patients Medical History
Email Address
*
Employer
*
Insurance co
*
Home Phone
*
Business Phone
Cell Phone
PATIENTS MEDICAL HISTORY
PHYSICIAN
OFFICE PHONE
Date
Are you under medical treatmet now?
Yes
No
Are you taking any medication(s) includig non-prescription medicine? If yes
Yes
No
Have you ever been hospitalized for any surgical operation or serious illness?
Yes
No
Have you even taken Fen-Phen/Redux?
Yes
No
Do you use Tabacco?
Yes
No
Do you use alcohol, cocaine or other drugs?
Yes
No
Are you wearing contact lenses?
Yes
No
Are you allergic to have you had any reactios to the following?
Local anesthetics(eg.novocale)
Yes
No
Barbiturates
Yes
No
Aspirin
Yes
No
Lodine
Yes
No
Peicillin or other atibiotics
Yes
No
Sedatives
Yes
No
Sulfa Drugs
Yes
No
Others
Do you have a persistent cough or throat clearing not associated with a known illness (lasting more than 3 weeks)?
Yes
No
Women Only
Are you pregnant or think you may be pregnant?
Yes
No
Are you nursing?
Yes
No
Are you taking birth control pills?
Yes
No
Do You have or have you had any of the following?
High blood pressure
Yes
No
Heart attack
Yes
No
Swollen ankles
Yes
No
Faintig / Seizures
Yes
No
Asthma
Yes
No
Low/High blood pressure
Yes
No
Epilepsy / Convulsions
Yes
No
Leukemia
Yes
No
Diabetes
Yes
No
Kidney Diseases
Yes
No
AIDS or HIV Infection
Yes
No
Thyroid Problem
Yes
No
Anemia
Yes
No
Rheumatic fever
Yes
No
Stomach troubles / Ulcers
Yes
No
Cardiac Pacemaker
Yes
No
Heart Murmur
Yes
No
Frequently tired
Yes
No
Angina
Yes
No
Heart Disease
Yes
No
Arthritis
Yes
No
Cancer
Yes
No
Emphysema
Yes
No
Joint Replacement or implant
Yes
No
Hepatitis / Jaundice
Yes
No
Sexually Transmitted disease
Yes
No
Chest Pains
Yes
No
Easily winded
Yes
No
Tuberculosis
Yes
No
Hay fever / Allergies
Yes
No
Stroke
Yes
No
Radiation Therapy
Yes
No
Glaucoma
Yes
No
Recent weight loss
Yes
No
Liver disease
Yes
No
Mitral valve prolapse
Yes
No
Respiratory problems
Yes
No
Others
Comments
Patients Dentail History
Do your gums bleed while brushing or flossig?
Yes
No
Are your teeth sensitive to hot or cold liquids/foods?
Yes
No
Are your teeth sensitive to sweet or sour liquids/foods?
Yes
No
Do you feel pain to any of your teeth?
Yes
No
Do you have any sores or lumps in or near your mouth?
Yes
No
Have you had any head, neck or jaw injuries?
Yes
No
Do you have frequent headaches?
Yes
No
Are your teeth sensitive to sweet or sour liquids/foods?
Yes
No
Do you have clench or grind your teeth?
Yes
No
Have you ever had any difficult extractions in the past?
Yes
No
Do you bite your lips or cheeks frequently?
Yes
No
Are your teeth sensitive to sweet or sour liquids/foods?
Yes
No
Have you had any arthodotic treatment?
Yes
No
Are your teeth sensitive to sweet or sour liquids/foods?
Yes
No
Are your teeth sensitive to sweet or sour liquids/foods?
Yes
No
Have you ever experienced any of the following problems in your jaw?
Clicking?
Yes
No
Difficulty in chewing?
Yes
No
Pain (Joint,ear,side of face)?
Yes
No
Difficulty in opening or closing?
Yes
No
Yes
i certify that i have read and understand the above iformation. To the best of my knowledge, the above questions have been accurately answered. I understand that providing incorrect information can be dangerous to my health.
Send Message
Go to Top
