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Medical Dental History Form
Medical Dental History Form
Patient Name
TODAY'S DATE
PATIENT MEDICAL HISTORY
Physician
Office Phone
Date Of Last Exam
1) Are You Under Medical Treatment Now?
No
Yes
2) Have You Ever Been Hospitalized For Any Surgical Opeation Or Serious Illness
No
Yes
If Yes, List
3) Are You Taking any Medication(s) Including None-Prescription Medicine
No
Yes
If Yes, What Medication(s) Are You Taking
4) Do You Use Tobacco
No
Yes
5) Do You Use Alcohol
No
Yes
6) Have You Used Any Illegal Substances
No
Yes
7) List Any Known Allergies
8) WOMEN ONLY
A) Are You Pregnant Or Think You May Be Pregnant
No
Yes
B) Are You Nursing
No
Yes
C) Are YouTaking Birth Control Pills
No
Yes
9) DO YOU HAVE OR HAVE YOU HAD ANY OF THE FOLLOWING?
Heart Murmur
No
Yes
Mental Disorders
No
Yes
Acid Reflux
No
Yes
Heart Disease/Trouble
No
Yes
Nervous Disorders
No
Yes
Hepatitis/Jaundice
No
Yes
Heart Attack
No
Yes
Asthma
No
Yes
Liver Disease
No
Yes
High Blood Pressure
No
Yes
Respiratory Problems
No
Yes
Kidney Disease
No
Yes
Low Blood Pressure
No
Yes
Tuberculosis
No
Yes
Diabetes
No
Yes
Stroke
No
Yes
Emphysema
No
Yes
Glaucoma
No
Yes
Cardiac Pacemaker/Defib.
No
Yes
HayFever/Allergies
No
Yes
AIDS or HIV Infection
No
Yes
Rheumatic Fever
No
Yes
Cancer
No
Yes
Sexually Transmitted
No
Yes
Angina
No
Yes
Leukemia
No
Yes
Disease
No
Yes
Chest Pain
No
Yes
Radiation Treatment
No
Yes
Joint Replacement Or Implant
No
Yes
Shortness OF Breath
No
Yes
Thyroid Problems
No
Yes
Swollen Ankles
No
Yes
Anemia
No
Yes
Arthritis
No
Yes
Fainting/Seizures
No
Yes
Stomach Troubles/Ulcers
No
Yes
Other
Doctor's Comments
PATIENT DENTAL HISTORY
1. Do Your Gums Bleed while Brushing or Flossing?
No
Yes
2. Are Your Teeth Sensitive to Hot Or Cold Liquids/Foods?
No
Yes
3. Are Your Teeth Sensitive to Sweet Or Sour Liquids/Foods?
No
Yes
4. Do You Feel Pain to Any of Your Teeth?
No
Yes
5. Do You Have Any Sores Or Lumps In Or Near Your Mouth?
No
Yes
6. Have You Had Any Head,Neck Or Jaw Injuries?
No
Yes
7. HAVE YOU EVER EXPERIENCED ANY OF THE FOLLOWING PROBLEMS IN YOUR JAW?
A) Clicking?
No
Yes
B) Pain (Joint, Ear, Side Of face)?
No
Yes
C) Difficulty in Opening Or Closing?
No
Yes
D) Difficulty in Chewing?
No
Yes
8) Do You Need Antibiotic Prophylaxis Prior To Dental Treatment?
No
Yes
9) Do You Have Frequent Headaches?
No
Yes
10) Do You Clench Or Grind Your Teeth?
No
Yes
11) Do You Bite Your Lips Or Cheeks Frequently?
No
Yes
12) Have You Had Any Orthodontic Work?
No
Yes
13) Have You Ever Had Prolonged Bleeding Following Extractions?
No
Yes
14) Have You Ever Had Instruction On The Correct Method Of Brushing Your Teeth?
No
Yes
15) Have You Ever Had Instruction On The Care Of Your Gums?
No
Yes
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