Download Health Questionnaire

DENTAL CENTER
MEDICAL HISTORY
DATE: ___________
PATIENT NAME _______________________________________________________
LAST
FIRST
MIDDLE INITIAL
BIRTH DATE: _____/_____/_______
What is your primary reason to see us today? ___________________________________________________________________________________________
Are you happy with your smile? □ YES □ NO
How would you rate your smile? (worst) 1 2 3 4 5 6 7 8 9 10 (best)
Are you interested in: Replacing any lost or missing teeth? □ YES □ NO
Whitening your teeth? □ YES □ NO
Have there been any changes in your general health within the past year?
□ YES □ NO
If yes, _______________________________________________
Have you been hospitalized or had a serious illness in the past two years?
□ YES □ NO
If yes, _______________________________________________
Previous operative/invasive procedures or surgeries?
□ YES □ NO
Teeth Straightening □ YES □ NO
If yes, what type? ____________________________________________________
Name/Address of Primary Care Physician: ________________________________________________________ Date of Last Physical Exam: ______________
Medications Currently Taking: ________________________________________________________________________________________________________
Do you use Tobacco Products? □ YES □ NO
If yes, what type/frequency? __________________________________________________________________
Please check if you take or have taken any of the following medications within the past two (2) years?
Antibiotics
□YES
□ NO
Steroids, (Cortisone,Prednisone)
□YES
□ NO
Prescriptions pain medications
Nitroglycerin
Non-prescription medications
□YES
□YES
□YES
□ NO
□ NO
□ NO
Anticoagulants (blood
thinners)
Bisphosphonates (Fosamax,
etc)
Blood Pressure Medications
Diabetes
Supplements/Herbal
Medications
□YES
□ NO
Aspirin
□YES
□ NO
□YES
□ NO
□YES
□ NO
□YES
□YES
□YES
□ NO
□ NO
□ NO
Anti-anxiety/
antidepressants
Heart Medications
Inhalers
If yes, What type?
□YES
□YES
□ NO
□ NO
Sickle Cell Disease
Bleeding disorder
Prolonged or abnormal bleeding
Blood transfusion
HIV or AIDS
Cancer
Leukemia or lymphoma
Chemotherapy
Head and neck radiation therapy
Psychiatric treatment
□YES
□YES
□YES
□YES
□YES
□YES
□YES
□YES
□YES
□YES
□ NO
□ NO
□ NO
□ NO
□ NO
□ NO
□ NO
□ NO
□ NO
□ NO
Milk products
□YES
□ NO
Latex
□YES
□YES
□ NO
□ NO
Please check if you have or have had any of the following diseases or problems?
High Blood Pressure
□YES □ NO Thyroid disease
□YES □ NO
Angina
□YES □ NO Hepatitis or Liver Disease
□YES □ NO
Heart Attack
□YES □ NO Kidney Disease
□YES □ NO
Pacemaker
□YES □ NO Epilepsy or seizure disorder □YES □ NO
Artificial heart valve
□YES □ NO Asthma
□YES □ NO
Congestive Heart Failure
□YES □ NO Lung Disease
□YES □ NO
Chest Pain
□YES □ NO Chronic Sinusitis
□YES □ NO
Shortness of Breath
□YES □ NO Season Allergies
□YES □ NO
Swelling of feet or ankles
□YES □ NO Reflux or GERD
□YES □ NO
Diabetes
□YES □ NO Arthritis
□YES □ NO
Any Artificial Joints
□YES □ NO
(hip/knee)?
Allergies (Please check if you are allergic or have adversely reacted to the following)
Local Anesthetics (lidocaine) □YES □ NO Non steroidals or other pain
□YES □ NO
medications
Antibiotics
Aspirin
Shellfish
Other health conditions
Women Only
Could you be pregnant?
Are you taking birth control
pills?
Staff Use Only (Notes)
□YES
□YES
□YES
□YES
□ NO
□ NO
□ NO
□ NO
Sedative medications
Iodine
□YES
□YES
□ NO
□ NO
Are you currently nursing?
If yes, what kind?
□YES
□YES
□ NO
□ NO
□YES
□ NO
If yes, date of last treatment :
Codeine or other narcotics
Please describe:
Patient Blood Pressure ____________________________________________
Patient Pulse Rate ________________________________________