Dental (E) DENTAL PATIENT MEDICAL HISTORY 4.2021

DENTAL PATIENT MEDICAL HISTORY
Name

First NameMiddle Initial Last Name
Date of Birth

MonthDayYear
Date
What is the purpose of your visit to our office today?
Do you have a toothache now?

YesNo
If yes, for how long?
On a scale of 0-10, with 10 being the most painful, what is your pain level today?
How confident are you filling out medical forms by yourself?

Not at allA little bitSomewhatQuite a bitExtremely

Please respond by picking the description that mostly closely answers

	Not At All	Several Days	Over Half the Days	Nearly Every Day
Over the past 2 weeks, have you had little interest or pleasure in doing things?
Over the past 2 weeks, have you felt down, depressed, or hopeless?

Personal Safety

	Yes	No
Do you feel safe at home?
Would you like to discuss your safety with your provider?

Circulatory System

	Yes	No	Dates if known and short description
Congenital heart disease, defect, or heart murmur?
Heart disease or congestive heart failure?
Heart attack?
High blood pressure (hypertension)?
Bacterial endocarditis?
Chest pain or angina?
Anemia or abnormal bruising or bleeding?
Do you have a pacemaker, defibrillator, or other artificial heart device?
Do you take blood thinners (e.g. Plavix, baby aspirin, Coumadin, warfarin)?

Immune System

	Yes	No	Dates if known and short description
Organ transplant or on organ transplant list?
Spleen removed?
Addison’s or Cushing’s disease, chronic steroid use (e.g. prednisone, etc.)
HIV or AIDS, or do you believe you have been exposed?
Lupus, rheumatoid arthritis, or any autoimmune condition?
Irritable bowel syndrome, Crohn’s disease, stomach ulcers, or gastric bypass?
Cancer, tumors, chemotherapy, or radiation?
Do you take medications that suppress your immune system (e.g. Remicade)?

Excretory System

	Yes	No	Dates if known and short description
Kidney problems, including dialysis?
Hepatitis? If so, what type and is it currently active?
Do you have any type of liver condition?

Endocrine System

	Yes	No	Dates if known and short description
Diabetes? If yes, what type?
Thyroid problems of any kind? If yes, was it high or low thyroid?
Do you take a thyroid medication (e.g. Synthroid, levothyroxine)?

Nervous System

	Yes	No	Dates if known and short description
Stroke?
Epilepsy, seizures, multiple sclerosis or a nervous system disorder?

Musculoskeletal System

	Yes	No	Dates if known and short description
Osteoporosis or taken medicine for osteoporosis? Please list.
Joint replacement (hip, knee, ankle, shoulder)?
Osteoarthritis (i.e. degenerative arthritis)?

Respiratory System

	Yes	No	Dates if known and short description
Asthma or chronic lung disease (e.g. emphysema, COPD, chronic bronchitis)?
Tuberculosis, histoplasmosis, cystic fibrosis, blastomycosis?

Reproductive System

	Yes	No	Dates if known and short description
Sexually transmitted disease (STD)?
WOMEN ONLY- Pregnant or potentially pregnant? If yes, how many weeks?
WOMEN ONLY- Breastfeeding?
WOMEN ONLY- Using birth control (other than physical barrier devices)?

Substance Use

	Yes	No	Dates if known and short description
Substance abuse (alcohol, drugs, illicit prescription drugs, huffing)?
Been on Pain Agreement, methadone, or Suboxone?
Treatment for Substance Use Disorder or in recovery?

Do you: (check all that apply)

SmokeChew tobaccoVapeUse e-cigarettesUse marijuana
Would you like help quitting?

YesNo

General Questions

	Yes	No	Dates if known and short description
Do you have any physical or mental disability requiring special consideration?
Experienced vertigo, dizziness, or fainting?
Have you ever had any type of operation or surgery? If yes, please list.
Have you ever been hospitalized? If yes, describe when and why.
Any disease or condition not listed? If yes, please list.

Have you recently experienced any of the following?

CoughingFever/ChillsMuscle painLoss of taste/smellShortness of breathSore throat
Do you have allergies or reactions to any of the following?

ChlorhexidineIodineLactoseLatexLocal AnestheticsMetalRed DyeSulfaSulfatesTree SapOther (foods, medications, etc.)

Please list all medications you currently take (include over-the-counter drugs and herbal supplements):

Date of last medical appointment?

MonthDayYear
Date
Purpose of that appointment?
Who is your primary care provider?
Please carefully read and sign the statement below.

The answers I have given above are true to the best of my knowledge. I am indicating my consent for routine diagnostic tests and procedures such as x-rays, cleaning, blood pressure, local anesthesia, fillings, crowns, and fluoride by signing below on behalf of myself or the above named minor in my guardianship.
Patient/Parent or Legal Guardian Signature*

Clear
Date

MonthDayYear
Date
Relationship to Patient
Should be Empty: