Medical History

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( * ) Marks field are mandatory to fill out

    Patient Name *

    Date Of Birth *

    PATIENT INFORMATION

    R (leave Blank if you do not understand question)

    ( * ) Marks field are mandatory to fill out

    Is your general health good? *

    YesNo

    Has there been a change in your health within the last year? *

    YesNo

    Have you been hospitalized or had a serious illness in the last three years? *

    YesNo

    If YES, why?

    Are you being treated by a physician now? *

    YesNo

    For what?

    Date of last medical exam? *

    Date of last Dental exam *

    Have you had problems with prior dental treatment? *

    YesNo

    Are you in pain now? *

    YesNo

    HAVE YOU EXPERIENCED

    ( * ) Marks field are mandatory to fill out

    Chest pain (angina)? *

    YesNo

    Swollen ankles? *

    YesNo

    Shortness of breath? *

    YesNo

    Recent weight loss, fever, night sweats? *

    YesNo

    Persistent cough, coughing up blood? *

    YesNo

    Bleeding problems, bruising easily? *

    YesNo

    Sinus problems? *

    YesNo

    Difficulty swallowing? *

    YesNo

    Diarrhea, constipation, blood in stools? *

    YesNo

    Frequent vomiting, nausea? *

    YesNo

    Difficulty urinating, blood in urine? *

    YesNo

    Dizziness? *

    YesNo

    Ringing in ears? *

    YesNo

    Headaches? *

    YesNo

    Fainting spells? *

    YesNo

    Blurred vision? *

    YesNo

    Seizures? *

    YesNo

    Excessive thirst? *

    YesNo

    Frequent urination? *

    YesNo

    Dry mouth? *

    YesNo

    Jaundice? *

    YesNo

    Joint pain, stiffness? *

    YesNo

     

    DO YOU HAVE OR HAVE YOU HAD

    ( * ) Marks field are mandatory to fill out

    Heart disease? *

    YesNo

    Heart attack, heart defects? *

    YesNo

    Heart murmurs? *

    YesNo

    Rheumatic fever? *

    YesNo

    Stroke, hardening of arteries? *

    YesNo

    High blood pressure? *

    YesNo

    Asthma, TB, emphysema, other lung diseases? *

    YesNo

    Hepatitis, other liver disease? *

    YesNo

    Stomach problems, ulcers? *

    YesNo

    Allergies to: drugs, foods, medications, latex? *

    YesNo

    Family history of diabetes, heart problems, tumors? *

    YesNo

    HIV+/AIDS *

    YesNo

    Tumors, cancer? *

    YesNo

    Arthritis, rheumatism? *

    YesNo

    Eye diseases? *

    YesNo

    Skin diseases? *

    YesNo

    Anemia? *

    YesNo

    VD (syphilis or gonorrhea)? *

    YesNo

    Herpes? *

    YesNo

    Kidney, bladder disease? *

    YesNo

    Thyroid, adrenal disease? *

    YesNo

    Diabetes? *

    YesNo

     

    DO YOU HAVE OR HAVE YOU HAD

    ( * ) Marks field are mandatory to fill out

    Psychiatric care? *

    YesNo

    Radiation treatments? *

    YesNo

    Chemotherapy? *

    YesNo

    Prosthetic heart valve? *

    YesNo

    Artificial joint? *

    YesNo

    Hospitalization? *

    YesNo

    Blood transfusions? *

    YesNo

    Surgeries? *

    YesNo

    Pacemaker? *

    YesNo

    Contact lenses? *

    YesNo

     

    ARE YOU TAKING

    ( * ) Marks field are mandatory to fill out

    Recreational drugs? *

    YesNo

    Drugs, medications, over-the-counter medicines
    (including Aspirin), natural remedies? *

    YesNo

    Tobacco in any form? *

    YesNo

    Alcohol? *

    YesNo

     

    WOMEN ONLY

    Are you or could you be pregnant or nursing?

    YesNo

    Taking birth control pills?

    YesNo

     

    ALL PATIENTS

    Do you have or have you had any other diseases or medical problems NOT listed on this form? If so, please explain

    To the best of my knowledge, I have answered every question completely and accurately. I will inform my dentist of any change in my health and/or medication.

    Patient Name *

    Date *

    Patient Name *

    Date Of Birth *

    PATIENT INFORMATION

    R (leave Blank if you do not understand question)

    ( * ) Marks field are mandatory to fill out

    Is your general health good? *

    YesNo

    Has there been a change in your health within the last year? *

    YesNo

    Have you been hospitalized or had a serious illness in the last three years? *

    YesNo

    If YES, why?

    Are you being treated by a physician now? *

    YesNo

    For what?

    Date of last medical exam? *

    Date of last Dental exam *

    Have you had problems with prior dental treatment? *

    YesNo

    Are you in pain now? *

    YesNo

    HAVE YOU EXPERIENCED

    ( * ) Marks field are mandatory to fill out

    Chest pain (angina)? *

    YesNo

    Swollen ankles? *

    YesNo

    Shortness of breath? *

    YesNo

    Recent weight loss, fever, night sweats? *

    YesNo

    Persistent cough, coughing up blood? *

    YesNo

    Bleeding problems, bruising easily? *

    YesNo

    Sinus problems? *

    YesNo

    Difficulty swallowing? *

    YesNo

    Diarrhea, constipation, blood in stools? *

    YesNo

    Frequent vomiting, nausea? *

    YesNo

    Difficulty urinating, blood in urine? *

    YesNo

    Dizziness? *

    YesNo

    Ringing in ears? *

    YesNo

    Headaches? *

    YesNo

    Fainting spells? *

    YesNo

    Blurred vision? *

    YesNo

    Seizures? *

    YesNo

    Excessive thirst? *

    YesNo

    Frequent urination? *

    YesNo

    Dry mouth? *

    YesNo

    Jaundice? *

    YesNo

    Joint pain, stiffness? *

    YesNo

     

    DO YOU HAVE OR HAVE YOU HAD

    ( * ) Marks field are mandatory to fill out

    Heart disease? *

    YesNo

    Heart attack, heart defects? *

    YesNo

    Heart murmurs? *

    YesNo

    Rheumatic fever? *

    YesNo

    Stroke, hardening of arteries? *

    YesNo

    High blood pressure? *

    YesNo

    Asthma, TB, emphysema, other lung diseases? *

    YesNo

    Hepatitis, other liver disease? *

    YesNo

    Stomach problems, ulcers? *

    YesNo

    Allergies to: drugs, foods, medications, latex? *

    YesNo

    Family history of diabetes, heart problems, tumors? *

    YesNo

    HIV+/AIDS *

    YesNo

    Tumors, cancer? *

    YesNo

    Arthritis, rheumatism? *

    YesNo

    Eye diseases? *

    YesNo

    Skin diseases? *

    YesNo

    Anemia? *

    YesNo

    VD (syphilis or gonorrhea)? *

    YesNo

    Herpes? *

    YesNo

    Kidney, bladder disease? *

    YesNo

    Thyroid, adrenal disease? *

    YesNo

    Diabetes? *

    YesNo

     

    DO YOU HAVE OR HAVE YOU HAD

    ( * ) Marks field are mandatory to fill out

    Psychiatric care? *

    YesNo

    Radiation treatments? *

    YesNo

    Chemotherapy? *

    YesNo

    Prosthetic heart valve? *

    YesNo

    Artificial joint? *

    YesNo

    Hospitalization? *

    YesNo

    Blood transfusions? *

    YesNo

    Surgeries? *

    YesNo

    Pacemaker? *

    YesNo

    Contact lenses? *

    YesNo

     

    ARE YOU TAKING

    ( * ) Marks field are mandatory to fill out

    Recreational drugs? *

    YesNo

    Drugs, medications, over-the-counter medicines
    (including Aspirin), natural remedies? *

    YesNo

    Tobacco in any form? *

    YesNo

    Alcohol? *

    YesNo

     

    WOMEN ONLY

    ( * ) Marks field are mandatory to fill out

    Are you or could you be pregnant or nursing? *

    YesNo

    Taking birth control pills? *

    YesNo

     

    ALL PATIENTS

    ( * ) Marks field are mandatory to fill out

    Do you have or have you had any other diseases or medical problems NOT listed on this form? If so, please explain *

    To the best of my knowledge, I have answered every question completely and accurately. I will inform my dentist of any change in my health and/or medication.

    Patient Name *

    Date *