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

Date of Birth:

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

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

Are you currently experiencing any dental pain or discomfort?

When was your last dental exam?

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

If yes, why? Please mark all that apply:


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)?

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®)

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®).

Are you taking hormonal replacements?

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

Do you use vaping products?

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

If yes, how often is your use?

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

WOMEN ONLY: Are you:

Taking birth control pills?

Pregnant?

Nursing?


ALLERGIES

Please check your answers to the following questions.

Aspirin

Barbiturates, sedatives or sleeping pills

Codeine or other narcotics

Hay fever/seasonal allergies

Iodine

Latex (rubber)

Local anesthetics

Metals

Penicillin or other antibiotics

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).

Other


MEDICAL & SURGICAL HISTORY

Date of last physical exam:

Please check your answers to the following questions.

Are you in good physical health?

Are you currently being seen or treated by a physician?

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

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

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

Have you had a heart valve replacement or heart surgery?

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

Have you traveled internationally within the last 30 days

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


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

Artificial (prosthetic) heart valve

Previous infective endocarditis

Congenital heart disease (CHD)

Unrepaired, cyanotic CHD

Repaired (completely) in last 6 months

Repaired CHD with residual defects

Arteriosclerosis

Coronary artery disease

Congestive heart failure

Damaged heart valves

Heart attack

Heart murmur/rhythm disorder

Rheumatic heart disease .

Stroke

Breathing (Respiratory) Health

Asthma (COPD)

Bronchitis

Emphysema

Sinus trouble

Tuberculosis

Cancer

Blood (Circulatory) Health

Anemia

Blood transfusion

Hemophilia

High or low blood pressure

Brain (Neurological)/Mental Health

Anxiety

Depression

Epilepsy

Mental health disorders

Neurological disorders

Post-traumatic stress disorder

Traumatic brain injury or concussion

Autoimmune Disease

AIDS or HIV Infection

Lupus

Digestive Health

Gastrointestinal disease

G.E. reflux/persistent heartburn (GERD)

Stomach ulcers

Eye (Vision) Health

Glaucoma

Other

Arthritis

Chronic pain

Diabetes (type I or II)

Eating disorder

Frequent infections

Hepatitis, jaundice or liver disease

Immune deficiency

Kidney problems

Malnutrition

Osteoporosis

Rheumatoid arthritis

Sexually transmitted infection (STI)

Thyroid problems


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?

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

Been exposed to anyone with tuberculosis?

Had a rapid or irregular heart beat?

Found it hard to catch your breath?

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

Noticed a change in your vision?

Fainted for no reason?

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

Had migraines or severe headaches?

E-Signature

Please sign electronically below.

Your browser does not support the signature


Sending data