Patient Health History
In case of Emergency (Person’s Name/Number): ________________________________________________________________________________________________________________________
Date of last Medical Exam: __________________________How would you describe your health? ______________________________________________________________________________
Do you have a Medical Physician: ___________________Name of Physician: _________________________________________________________________________________________________
1. Are you now or have you been under the care of a physician within the past five years: ________If so, why: ________________________________________________________
2. Have you had any major surgery/hospitalization: ______________________________________________________________________________________________________________
3. Are you now or have you recently been taking any medication? __________If yes, name of meds and for what _______________________________________________________ _____________________________________________________________________________________________________________________________________________________________
4. Have you taken Phen-fen/Redux before? ______________When? ________________Have you seen your physician after that? __________________________________________
5. Are you allergic to or have any reactions to any of the following: (mark each applicable box)
Y N Y N Y N
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Local Anesthetics (e.g. Lidocaine) |
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Aspirin |
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Iodine |
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Penicillin or any antibiotics |
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Codeine |
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Latex Rubber |
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Sulfa Drugs |
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Barbiturates |
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Others (please list) |
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Any metals (e.g., nickel, mercury |
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Sedatives |
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6. Women Only:
Y N
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Are you pregnant or think you may be pregnant? |
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Are you nursing? |
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Are you practicing birth control medication? |
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7. Do you or have you had any of the following: (please mark each applicable box)
Y N Y N Y N Y N
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Heart Attack |
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Joint Replacement/Implant |
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Epilepsy |
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Cold Sores |
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Heart Failure |
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Kidney Trouble |
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Glaucoma |
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Genital Herpes |
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Heart Surgery |
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Ulcers |
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Pain in Jaw Joints |
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Fainting/Dizzy Spells |
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Heart Disease |
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Arthritis |
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AIDS/HIV infection |
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Nervousness |
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Angina Pectoris |
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Emphysema |
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Liver Disease |
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Psychiatric Treatment |
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Heart Murmur |
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Tuberculosis |
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Hepatitis A (infectious) |
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Sickle Cell Disease |
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High Blood Pressure |
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Asthma |
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Hepatitis B (serum) |
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Bleeding Gums |
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Rheumatic Fever |
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Hay Fever/Allergies |
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Hepatitis C |
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Tooth Pain |
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Congenital Heart Defect |
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Sinus Trouble |
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Yellow Jaundice |
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Bad Breath |
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Scarlet Fever |
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Diabetes |
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Blood Transfusion |
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Chronic Headaches |
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Artificial Heart Valve |
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Thyroid Disease |
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Drug Addiction |
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Chronic Neckaches |
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Mitral Valve Prolapse |
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Radiation Therapy |
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Hemophilia |
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Cosmetic Surgery |
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Heart Pace Maker |
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Chemotherapy |
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Syphilis |
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Cortisone Medicine |
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Stroke |
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Cancer |
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Leukemia |
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Others (please list) |
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High Cholesterol |
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Tobacco/nicotine use |
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Gonorrhea |
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Patient Dental History
Name of Previous Dentist and Location _________________________________________________________________Date of Last Exam: ______________________________________
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Do your gums bleed while brushing or flossing? |
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Do you have frequent headaches? |
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Are your teeth sensitive to hot or cold liquids/foods? |
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Do you clench or grind your teeth? |
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Are your teeth sensitive to sweet or sour liquids/foods? |
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Do you bite your lips or cheeks frequently? |
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Do you feel pain in any of your teeth? |
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Have you ever had any difficulty with extractions? |
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Do you have any sores or lumps in or near your mouth? |
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Have you ever had any prolonged bleeding after extractions? |
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Have you had any head, neck, or jaw injuries? |
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Have you had any orthodontic treatment? |
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Have you ever experienced any of the following in your jaw? |
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Do you wear dentures or partials? If yes, date of placement? ____________________ |
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a) Clicking |
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Have you ever received oral hygiene instructions (teeth and gums)? |
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b) Pain (joint, ear, side of face) |
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Do you like your smile? |
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c) Difficulty in opening or closing |
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d) Difficulty in chewing |
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Authorization and Release: I certify that I have read and understand the above information 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. I authorize the dentist to release any information including the diagnosis and the records of any treatment or examination rendered to me or my child during the period of such dental care to third party payors and /or health practitioners.
Signature of Patient/Parent or Guardian: _______________________________________________________________________Date: ______________________________________________
Doctor’s Signature: ______________________________________________________________________________________________Date: ______________________________________________
Doctor’s Comments: _________________________________________________________________________________________________________________________________________________