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                                                                                                   

Local Anesthetics (e.g. Lidocaine)

 

 

Aspirin

 

 

Iodine

 

 

Penicillin or any antibiotics

 

 

Codeine

 

 

Latex Rubber

 

 

Sulfa Drugs

 

 

Barbiturates

 

 

Others (please list)

 

 

Any metals (e.g., nickel, mercury

 

 

Sedatives

 

 

 

 

 

       

         6.    Women Only:

                                                                                                                               Y   N

Are you pregnant or think you may be pregnant?

 

 

Are you nursing?

 

 

Are you practicing birth control medication?

 

 

 

7.        Do you or have you had any of the following: (please mark each applicable box)

                                                      Y  N                                                    Y   N                                              Y   N                                           Y   N

Heart Attack

 

 

Joint Replacement/Implant

 

 

Epilepsy

 

 

Cold Sores

 

 

Heart Failure

 

 

Kidney Trouble

 

 

Glaucoma

 

 

Genital Herpes

 

 

Heart Surgery

 

 

Ulcers

 

 

Pain in Jaw Joints

 

 

Fainting/Dizzy Spells

 

 

Heart Disease

 

 

Arthritis

 

 

AIDS/HIV infection

 

 

Nervousness

 

 

Angina Pectoris

 

 

Emphysema

 

 

Liver Disease

 

 

Psychiatric Treatment

 

 

Heart Murmur

 

 

Tuberculosis

 

 

Hepatitis A (infectious)

 

 

Sickle Cell Disease

 

 

High Blood Pressure

 

 

Asthma

 

 

Hepatitis B (serum)

 

 

Bleeding Gums

 

 

Rheumatic Fever

 

 

Hay Fever/Allergies

 

 

Hepatitis C

 

 

Tooth Pain

 

 

Congenital Heart Defect

 

 

Sinus Trouble

 

 

Yellow Jaundice

 

 

Bad Breath

 

 

Scarlet Fever

 

 

Diabetes

 

 

Blood Transfusion

 

 

Chronic Headaches

 

 

Artificial Heart Valve

 

 

Thyroid Disease

 

 

Drug Addiction

 

 

Chronic Neckaches

 

 

Mitral Valve Prolapse

 

 

Radiation Therapy

 

 

Hemophilia

 

 

Cosmetic Surgery

 

 

Heart Pace Maker

 

 

Chemotherapy

 

 

Syphilis

 

 

Cortisone Medicine

 

 

Stroke

 

 

Cancer

 

 

Leukemia

 

 

Others (please list)

 

 

High Cholesterol

 

 

Tobacco/nicotine use

 

 

Gonorrhea

 

 

 

 

 

 

Patient Dental History

Name of Previous Dentist and Location _________________________________________________________________Date of Last Exam: ______________________________________

                                                                                                             Y   N                                                                                                                                            Y      N

Do your gums bleed while brushing or flossing?

 

 

Do you have frequent headaches?

 

 

Are your teeth sensitive to hot or cold liquids/foods?

 

 

Do you clench or grind your teeth?

 

 

Are your teeth sensitive to sweet or sour liquids/foods?

 

 

Do you bite your lips or cheeks frequently?

 

 

Do you feel pain in any of your teeth?

 

 

Have you ever had any difficulty with extractions?

 

 

Do you have any sores or lumps in or near your mouth?

 

 

Have you ever had any prolonged bleeding after extractions?

 

 

Have you had any head, neck, or jaw injuries?

 

 

Have you had any orthodontic treatment?

 

 

Have you ever experienced any of the following in your jaw?

 

 

Do you wear dentures or partials? If yes, date of placement? ____________________     

 

 

                   a) Clicking

 

 

Have you ever received oral hygiene instructions (teeth and gums)?

 

 

                   b) Pain (joint, ear, side of face)

 

 

Do you like your smile?

 

 

                   c) Difficulty in opening or closing

 

 

 

 

 

                   d) Difficulty in chewing

 

 

 

 

 

 

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: _________________________________________________________________________________________________________________________________________________

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