Welcome!

Please enter the patient's name below:

First Name

Last Name

Dental Health History

Date of last health care exam

What was this exam for?

Have you been hospitalized in the last 5 years?

Yes

No

Explain:

Health Conditions

For the following questions, select Yes or No. Your answers are for our records only and will be confidential. Please note that during your initial visit you will be asked some questions about your response. Our team may ask additional questions concerning your health

Heart Murmur (mitral valve prolapse)

Yes

No

Psychosis

Yes

No

Anemia

Yes

No

Sore/Enlarged Lymph Nodes

Yes

No

Diabetes

Yes

No

Previous Biopsies

Yes

No

Epilepsy

Yes

No

Slow-Healing Mouth Sores

Yes

No

Hepatitis, Any Form

Yes

No

Other Infections

Yes

No

Rheumatic Fever

Yes

No

Recurrent Illnesses

Yes

No

Asthma

Yes

No

Joint Replacement

Yes

No

HIV Positive or AIDS Related Complex

Yes

No

Glaucoma

Yes

No

Emphysema or other Respiratory Illnesses

Yes

No

Abnormal Bleeding From a Cut

Yes

No

Abnormal Heart Condition

Yes

No

Liver Disease (including Jaundice)

Yes

No

Kidney Disease

Yes

No

Unintentional Weight Loss/Gain

Yes

No

Heart (Surgery, Disease, Attack)

Yes

No

Latex Sensitivity

Yes

No

Venereal Disease

Yes

No

Other

Yes

No

If other, please explain:

Are you required to Pre-Medicate before dental treatment?

Yes

No

If yes, what medication:

Female Patients

Are you a female patient?

Yes

No

Other Medical Conditions

Abnormal Blood Pressure?

Yes

No

If yes, what is it usually:

Are you allergic or have you had a reaction to:

Local anesthetics

Yes

No

Penicillin or other antibiotics

Yes

No

Aspirin

Yes

No

Codeine, valium or other sedatives

Yes

No

Other

Yes

No

If other, please list:

Are you a smoker?

Yes

No

If so, how much do you smoke per day?

Please list any medications you are currently taking:

Are you taking Tagamet (Cimetidine)?

Yes

No

If yes, how often?

Do you take Antacids?

Yes

No

If yes, how often do you take Antacids?

Are you taking herbal supplements/medications?

Yes

No

If yes, how often are you taking herbal supplements/medications?

Diet

Are you on a Restricted Diet?

Yes

No

If yes, how many meals a day?

Do you have any Food Allergies?

Yes

No

If yes, to what?

Sugar in your diet:

None

Slight

Moderate

High

Headaches, TMJ pain

Do you have Severe Migranes: 15 days/month, 4 hrs minimum?

Yes

No

Do you have Occasional or Mild Migrane headaches?

Yes

No

Do you have TMJ pain?

Yes

No

Do you use a Night Guard?

Yes

No

Have you received any Botox or Dermal Fillers in the past?

Yes

No

Any other issues regarding your medical or dental history?

Dental management special requests:

Signature

Patient Signature

Clear

Date today:

IN OFFICE USE ONLY

Are you a member of staff?

Yes

No

0%