Medical and Dental History Form

Patient Name*
DOB*
MM slash DD slash YYYY
Sex*
Medical History
Name of Physician*
Phone*
Physician's Address*
When was your last physical?
MM slash DD slash YYYY
Are your immunizations up to date?*
- Yes
- No
Are you now under the care of a physician?*
- Yes
- No
If yes for what reason?*
Are you presently taking any medications/drugs/pills?*
- Yes
- No
Please list*
Are you allergic (or have an adverse reaction) to?
- Penicillin
- Codeine
- Local Anesthetic
- Aspirin
- None
- Other
- Other Antibiotic
Please describe
Are you sensitive or allergic to latex? (i.e. Experienced itching, rash or wheezing after using latex gloves or handling a balloon)*
- Yes
- No
If yes, please explain*
Have you had any usunual or unexplained reactions during a surgical procedure?*
- Yes
- No
If yes please explain*
Do you have, or have had any of the following: (Yes or No)
Abnormal Blood Pressure*
- Yes
- No
Epilepsy*
- Yes
- No
Osteoporosis*
- Yes
- No
Alcohol Addiction*
- Yes
- No
Fainting Spells*
- Yes
- No
Prolonged Bleeding*
- Yes
- No
Anemia*
- Yes
- No
Glaucoma*
- Yes
- No
Prosthetic Implants*
- Yes
- No
Anorexia*
- Yes
- No
Hearing Impaired*
- Yes
- No
Psychiatric Care*
- Yes
- No
Arthritis/Reumatism*
- Yes
- No
Heart Disease/Surgery*
- Yes
- No
Radiation Therapy*
- Yes
- No
Artificial Heart Valve*
- Yes
- No
Heart Murmur*
- Yes
- No
Removal of Spleen*
- Yes
- No
Artificial Joint*
- Yes
- No
Heart Pace Maker*
- Yes
- No
Rheumatic Fever*
- Yes
- No
Asthma*
- Yes
- No
Hemophilia*
- Yes
- No
Rheumatic Heart Disease*
- Yes
- No
Bulimia*
- Yes
- No
Hepatitis*
- Yes
- No
Hepatitis Type
- A
- B
- C
Sickle Cell Disease*
- Yes
- No
Cancer*
- Yes
- No
HIV Positive / AIDS*
- Yes
- No
Sinus Trouble*
- Yes
- No
Chemical Dependency*
- Yes
- No
Kidney Problems*
- Yes
- No
Stroke*
- Yes
- No
Chemotherapy*
- Yes
- No
Learning Disability*
- Yes
- No
Thyroid Problems*
- Yes
- No
Congenital Heart Disease*
- Yes
- No
Liver Disease*
- Yes
- No
Tuberculosis*
- Yes
- No
Cortisone Medicine*
- Yes
- No
Lung Disease*
- Yes
- No
Tumors*
- Yes
- No
Diabetes*
- Yes
- No
Mitral Valve Prolapse*
- Yes
- No
Ulcers*
- Yes
- No
Recreational Drugs*
- Yes
- No
Neurological Disorders*
- Yes
- No
Venereal Disease*
- Yes
- No
Emphysema*
- Yes
- No
Organ Transplant*
- Yes
- No
Have you had any other serious illness, hospitalization or accident*
- Yes
- No
If yes, please explain
Do you currently smoke or use the following tobacco products?
- Cigarettes
- Cigars
- Pipe
- Chew
- None
Have you used tobacco products in the past?*
- Yes
- No
If yes how long ago?
Do you drink alcoholic beverages?*
- Yes
- No
If yes, how much?*
Women: Are you pregnant?*
- Yes
- No
Estimated due date*
MM slash DD slash YYYY
Are you nursing?*
- Yes
- No
Do you take birth control?*
- Yes
- No
Comments
Dental History
Date of Last Dental Visit*
MM slash DD slash YYYY
Do your gums bleed while brushing or flossing?*
- 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
Do you clench or grind your teeth?*
- Yes
- No
Have you experienced any of the following*
- Yes
- No
- Clicking in jaw
- Pain (joint, ear, side of face)
- Difficulty in opening or closing mouth
- Difficulty in chewing
Have you ever had any orthodontic work?*
- Yes
- No
Have you ever had prolonged bleeding following extractions?*
- Yes
- No
Have you ever had instruction on the correct method of brushing your teeth?*
- Yes
- No
Have you ever had instructions on the care of your gums?*
- Yes
- No
Comments
FOR MINORS (under age 18):
Patient Name
Patient/Guardian Signature
First Name*
Last Name*
Email*
Date*
MM slash DD slash YYYY

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