Patient Dental & Medical Health History Information

To our patients: Please know that we may ask follow-up questions to make sure we have all of the information we need in order to treat you.

PATIENT INFORMATION

Today's Date:

Last Name:

First Name:

Middle Name:

Home Phone:

Cell Phone:

Work Phone:

Email Address:

Mailing Address:

City:

State:

Zip:

Date of Birth:

Birth month

Birth day

Birth year

Gender:

Occupation:

Emergency Contact Name:

Emergency Contact Relationship:

Emergency Contact Phone:

If you are completing this form for another person, what is your name and relationship to that person?

Name:

Relationship:

If executing this form as the patient’s personal representative, I represent and warrant that I have full legal right and authority to consent to the performance of any procedure(s) on this patient. If for any reason I no longer have such legal right and authority, I will immediately notify the practice in writing.

DENTAL HISTORY & SYMPTOMS

What is the reason for your visit today?

Are you currently experiencing any dental pain or discomfort?

Yes

If yes where?

When was your last dental exam?

Month

Day

Year

What was done at that appointment?

When was the last time you had dental xrays taken

Please check in the box ONLY if this applies to you.

Is it hard to open your mouth?

Does it hurt to chew, bite or swallow?

Do your gums bleed when you brush or floss your teeth?

Have you ever had periodontal (gum) treatments like scaling and root planing?

Do you have, or have you ever had, any sores or growths in your mouth?

Do you clench or grind your teeth?

Does your jaw click, pop or hurt?

Do you have earaches or neck pains?

Does dental treatment make you nervous?

Have you ever experienced any of these sleep-related breathing disorders?

Mouth breathing

Snoring

Trouble breathing during sleep

Have you ever had a serious injury to your head or mouth?

If yes please describe what happened and when it happened:

Have you ever had problems with dental treatment in the past?

If yes please describe what happened

Have you ever had a reaction to, or problem with, dental anesthesia?

If yes please describe what happened:

Are you unhappy with your smile?

If yes, why? Please mark all that apply:

The color of your teeth

The shape of your teeth

The position of your teeth

Other.

Please describe

MEDICATIONS & OTHER PRODUCTS/SUBSTANCES

Please check in the box ONLY if this applies to you.

Are you taking any blood thinners (such as Coumadin, Warfarin, rivaroxaban (Xarelto®), dabigatran (Pradaxa®), clopidogrel (Plavix®), heparin or aspirin)?

Yes

If yes, what medication are you taking?

Are you taking any medication to treat osteoporosis or Paget’s disease?
Some commonly-prescribed drugs include alendronate (Fosamax®), risedronate (Actonel®), ibandronate (Boniva®), zolendronate (Reclast®), and denosumab (Prolia®)

Yes

If yes, what medication are you taking?

Are you taking, or scheduled to take, an IV medication to treat bone pain, hypercalcemia or skeletal complications resulting from Paget’s disease, multiple myeloma or metastatic cancer?
Some commonly-prescribed drugs include denosumab (Xgeva®), pamidronate (Aredia®) or zolendronate (Zometa®).

Yes

If yes, what medication are you taking?

How many years have you been taking it?

Are you taking hormonal replacements?

Yes

Do you use any form of tobacco or nicotine products (cigarettes, cigars, snuff, chew, bidis)?

Yes

Do you use vaping products?

Yes

How many alcoholic beverages do you have per week?

Do you use controlled substances (drugs), including marijuana, for either medicinal or recreational reasons?

Yes

If yes, what substances?

If yes, how often is your use?

Daily

Several times per wee

Weekly

Occasionally

Yes

If yes, for what reason(s)?

Do you take any other prescriptions and/or over-the-counter medicine(s), vitamins, herbs and/or supplements?

Yes

If yes, please list them here and include information about how much and how often you use each one.

WOMEN ONLY: Are you:

Taking birth control pills?

Yes

Pregnant?

Yes

If yes, number of weeks:

Nursing?

Yes

If yes number of weeks:

ALLERGIES

Please check your answers to the following questions.

Aspirin

Yes

Barbiturates, sedatives or sleeping pills

Yes

Codeine or other narcotics

Yes

Hay fever/seasonal allergies

Yes

Iodine

Yes

Latex (rubber)

Yes

Local anesthetics

Yes

Metals

Yes

Penicillin or other antibiotics

Yes

Sulfa drugs such as sulfamethoxazole-trimethoprim (Septra, Bactrim), erythromycin-sulfisoxazole, sulfasala-zine (Azulfidine), erythromycin- sulfisoxazole (Eryzole, Pediazole) glyburide (Diabeta, Glynase PresTabs), dapsone, sumatriptan (Imitrex), celecoxib (Celebrex), hydrochlorothiazide (Microzide) and furosemide (Lasix).

Yes

Other

Yes

Please describe any “Yes” answers and include information about your experience.

MEDICAL & SURGICAL HISTORY

Date of last physical exam:

Month

Day

Year

What is your normal blood pressure (systolic, diastolic)?

Doctor's Name

Phone

Please check your answers to the following questions.

Are you in good physical health?

Yes

Are you currently being seen or treated by a physician?

Yes

Has a physician or previous dentist recommended that you take antibiotics before having dental work done?

Yes

Have you had a serious illness, operation or been hospitalized in the past 5 years?

Yes

Have you had any type (either total or partial) of joint replacement surgery (such as for a hip, knee, shoulder, elbow, finger, etc.)?

Yes

Have you had a heart valve replacement or heart surgery?

Yes

Have you had an organ or bone marrow/stem cell transplant?

Yes

Have you traveled internationally within the last 30 days

Yes

Have you had a fever (100.4oF or above) in the last 72 hours?

Yes

If you answered yes to any of the above, please explain?

MEDICAL HISTORY SPECIFIC Please check your answers to the following questions.

Do you have, or have you been diagnosed with, any of the following conditions?

Heart (Cardiac) Health

Pacemaker/implanted defibrillator

Yes

Artificial (prosthetic) heart valve

Yes

Previous infective endocarditis

Yes

Congenital heart disease (CHD)

Yes

Unrepaired, cyanotic CHD

Yes

Repaired (completely) in last 6 months

Yes

Repaired CHD with residual defects

Yes

Arteriosclerosis

Yes

Coronary artery disease

Yes

Congestive heart failure

Yes

Damaged heart valves

Yes

Heart attack

Yes

Heart murmur/rhythm disorder

Yes

Rheumatic heart disease .

Yes

Stroke

Yes

Breathing (Respiratory) Health

Asthma (COPD)

Yes

Bronchitis

Yes

Emphysema

Yes

Sinus trouble

Yes

Tuberculosis

Yes

Cancer

Yes

Type:

Date of diagnosis:

Chemotherapy:

Radiation treatment:

Blood (Circulatory) Health

Anemia

Yes

Blood transfusion

Yes

If yes, date:

Hemophilia

Yes

High or low blood pressure

Yes

Brain (Neurological)/Mental Health

Anxiety

Yes

Depression

Yes

Epilepsy

Yes

Mental health disorders

Yes

Neurological disorders

Yes

Post-traumatic stress disorder

Yes

Traumatic brain injury or concussion

Yes

Autoimmune Disease

AIDS or HIV Infection

Yes

Lupus

Yes

Digestive Health

Gastrointestinal disease

Yes

G.E. reflux/persistent heartburn (GERD)

Yes

Stomach ulcers

Yes

Eye (Vision) Health

Glaucoma

Yes

Other

Arthritis

Yes

Chronic pain

Yes

Diabetes (type I or II)

Yes

Eating disorder

Yes

Frequent infections

Yes

Type of infection:

Hepatitis, jaundice or liver disease

Yes

Immune deficiency

Yes

Kidney problems

Yes

Malnutrition

Yes

Osteoporosis

Yes

Rheumatoid arthritis

Yes

Sexually transmitted infection (STI)

Yes

Thyroid problems

Yes

Do you have any disease, condition, or problem thats not listed here? If so please explain.

MEDICAL SYMPTOMS/GENERAL

Please check your answers to the following questions

In the past 30 days, have you:

Had pain or tightness in the chest?

Yes

Coughed up blood or had a cough that lasted longer than 3 weeks?

Yes

Been exposed to anyone with tuberculosis?

Yes

Had a rapid or irregular heart beat?

Yes

Found it hard to catch your breath?

Yes

Had a high fever (greater than 101.5˚F) for no reason? .

Yes

Noticed a change in your vision?

Yes

Fainted for no reason?

Yes

Experienced vomiting, diarrhea, chills, night sweats or bleeding?.

Yes

Had migraines or severe headaches?

Yes

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