DENTAL HISTORY

PERSONAL INFORMATION
NAME ________________
DATE______________________
AGE______________
NUMBER________________

CELL

GENDER____________
OCCUPATION___________________
ADRESS__________________

MARTIAL STATUS________________

PRESENTING COMPLAIN
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HISTORY OF PRESENT ILNESS

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PAST MEDICAL HISTORY

Have you ever had any of the following? Please tick those that apply:

_ Anaemia
_ Artificial joint
_ Asthma
distress
_ Blood Disease
_ Cancer
_ Dizziness
_ Epilepsy
_ Excessive Bleeding
_ Diabetes

_ Fainting
_ Glaucoma
_ Heart Disease

_ Pacemaker
_ Radiation Therapy
_ Respiratory

_ Heart Murmur
_ Hepatitis A, B, C
_ Jaundice
_ Kidney Disease
_ Liver Disease
_ HIV/ AIDS

_ Rheumatic fever
_ Sinus problems
_ Stroke
_ Tuberculosis
_ Tumours
_ Psychological

SYSTEMIC HISTORY
GENERAL
FEVER
SWEAT
GENITOURINARY
URINE FREQUENCY
BLOOD IN URINE
DIFFICULTY IN URINATION
SKIN
RASHES
MOLES
ITCHING
ENDOCRINE SYSTEM
HEAT INTOLERENCE
COLD INTOLERENCE
ALLERGY
ITCHY EYES
RUNNING NOSE
NASAL CONGESION
POST NASAL DRIP

EYE
BLURRED VISION
CHANGING VISION
RESPIRATION
COUGH
DYSPENA
WEEZING
CVS
CHEST PAIN
ANKEL SWELLING
PALPATIONS
CNS
HEADACHES
WEAKNESS
NUMBNESS
GIT
NAUSEA
VOMITTING
ABDOMINAL PAIN
DIRREAH
MUKOSKELETAL
JOINTS SWELLING
JOINT PAIN
MUSCLE PAIN

DRUG HISTORY
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FAMILY HISTORY
FAMILY HISTORY:

Has anyone in your family had any of the following? (Check

appropriate box)
Mother
High Blood Pressures/
Hypertension
Heart Attack/
Heart Surgery
Diabetes
Stroke
Cancer
(Type/Location)
Osteoporosis

Father

Brothers /Sisters

Thyroid Problems
Mental Illness
Glaucoma

ALLERGIES

PERSONAL & SOCIO-ECONOMIC STATUS

Have you ever used tobacco products? Yes No
What kind? ______________________________
How much? ______________________________
For how many years? ______________________
Date quit?________________________________
Do you drink alcohol? Yes No
How many drinks per week? _______
Have you ever felt you need to cut down? Yes No
Have you ever felt guilty about our drinking? Yes No
Do you use drugs? Yes No What type?___________
How often?______________________________________
Do you have guns in your home? ______
Do you exercise outside of your job?______
Do you wear seatbelts? always usually sometimes never
What is your occupation? _________________________
Who do you live with?_________________________

DENTAL HISTORY
Are you concerned about or experiencing any of the following dental
problems? (please tick as many asit applies)
sensitivity to hot or cold____ food trapping between your teeth_____
clicking/pain in the jaw joints_____ staining of your teeth________
discoloured fillings_______ roughness of existing fillings__________
bleeding gums ________bad breath_________ sensitivity when eating_____
head/neck ache______ grinding or clenching of your teeth______
What is the main purpose of your visit today?
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__________________
How long since your last dental visit?
____________________________________________

GENERAL PHYSICAL EXAMINATION

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EXTRA-ORAL EXAMINATION

INTRA-ORAL EXAMINATION
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INVESTIGATIONS
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DIFFERENTIAL DIAGNOSIS
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DIAGNOSIS

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