Dental Patient Medical History

Patient Name

Social Security Number

Date of Birth

Home or Cell Phone Number

Work Phone Number

Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Reason for Dental Visit?

Type a question

Yes

No

Specify

Organ Transplant - Specify Date

Joint Replacement (hip, knee, ankle, shoulder) - Specify Date

Artificial Heart Valve - Specify Date

Congenital Heart Disease, Defect, or Heart Murmur

Bacterial Endocarditis (SBE)

Kidney Problems or Dialysis - Specify Which

Spleen Removed

Steroid Use (e.g prednisone) - Specify Dates

HIV or AIDS or do you believe you have been exposed?

Lupus (SLE)

Rheumatoid Arthritis

Diabetes - Specify Type I or Type II

Other Immunosuppressive Condition - Specify

Hepatitis - Specify Past or Current

Other Liver Disease - Specify

Pacemaker/Defibrillator or Other Artificial Device/Implant - Specify Date

Congestive Heart Failure

Heart Disease or Heart Attack - Specify Dates

Chest Pain/ Angina

High Blood Pressure

Have you or are you taking blood-thinners?

Anemia or Abnormal Bleeding or Bruising

Epilepsy, Seizures, or Nervous System Disease

Stroke

Cancer/Tumors - Specify Dates

Chemotherapy or Radiation - Specify Dates

Tuberculosis - Specify Currently or In Past

Asthma or Other Lung Disease

Ulcers

Arthritis

Osteoporosis

Thyroid Problems - Specify High or Low

Mental Health Condition - Specify

Chemical Dependency (Alcohol/ Other Drug)

Physical or Mental Disability that Requires Special Consideration - Specify

Do you smoke or chew tobacco?

If yes, are you interested in quitting?

Any other disease or condition? - Specify

Please answer the following questions only if you are a woman.

Yes

No

Are you pregnant?

Are you nursing?

Are you taking birth control?

Are you allergic to any of the following?

Latex Iodine Red Dye Metal Local Anesthetics None of the above

Please indicate if you have taken any of the following medication (usually for osteoporosis or as part of chemotherapy).

Please list any medications you may be allergic to or which make you sick.

Please list any medications you are currently taking (including over-the-counter drugs).

Date of last medical appointment?

Date

Primary Care Provider Name

Have you ever been hospitalized?

Please describe when and why you were hospitalized.

The answers I have given above are true to the best of my knowledge. I am signing below on behalf of myself or the above named minor in my guardianship.

Signature

Clear

Date