Medical History

Today’s Date_______________
Patient Name____________________________________________
Name of Physician__________________________Date of Last Physical Exam______________Age__________
Physician's Address/Phone #___________________________________________________________________

Do you have or have you had any of the following?

Yes/No Yes/No Yes/No
___ ___ AIDS/HIV+ ___ ___ Drug Addiction ___ ___ Psychological Problems
___ ___ Allergies ___ ___ Adverse Drug Reaction ___ ___ Radiation Hd/NeckCancer
___ ___ Anemia ___ ___ Endocrine Problems ___ ___ Rheumatic Fever
___ ___ Arthritis ___ ___ Epilepsy (Seizures) ___ ___ Sinus Problems
___ ___ Asthma/Hayfever ___ ___ Frequent Fainting ___ ___ Shortness of
Breath
___ ___ Bleeding Problems ___ ___ Frequent Headaches ___ ___ Stomach/IntestinalDisease
___ ___ Blood Diseases ___ ___ Glaucoma ___ ___ Stroke
___ ___ Blood Transfusion ___ ___ Head Injury ___ ___ Swelling (Hands or Feet)
___ ___ Bruise Easily ___ ___ Heart Disease ___ ___ Thyroid Diseases
___ ___ Cancer or Tumor ___ ___ Heart Murmur ___ ___ TB/Other Lung Disease
___ ___ Chemotherapy ___ ___ Hepatitis (Jaundice) ___ ___ Ulcer
___ ___ Chest Pains/Angina ___ ___ High/Low Blood Pressure ___ ___ Urinary Problems
___ ___ Cortisone/Steroids ___ ___ Kidney Disease ___ ___ Sexually Transmitted Dis.
___ ___ Cough (Persistent) ___ ___ Liver Disease ___ ___ Other (Please Specify)
___ ___Diabetes ___ ___ Prosthetic Joints/ __________________
___ ___Family History of Diabetes Heart Valves __________________
Describe any current medical treatment including drugs taken currently, or in recent past (including aspirin/ibuprofen).
_____________________________________________________________________________________________
Are you taking or have you ever taken bisphosphonates for osteoporosis or
chemotherapy?_____________________

Yes/No
___ ___ Are you allergic to any medications? Please list______________________________________________
___ ___ Have you been seriously ill in the past 5 years? Please explain.__________________________________
___ ___ Do you use tobacco products? If so, state type, amt/day and approximate # of years._________________
___ ___ Do you drink alcohol? If so, please state type and amt/day_____________________________________
Women Only
___ ___ Are you nursing, or or you pregnant? If so, what month?_______________________________________
___ ___ Are you taking Birth Control Pills? If so, how long?_________________________________________
___ ___ Are you in, or have you been through menopause?___________________________________________

Dental History

Yes/No Do You... Yes/No Have you...

___ ___ Fear the dentist/dental treatment?
___ ___ Grind or frequently clench your teeth?
___ ___ Have an unpleasant taste in your mouth?
___ ___ Have pain opening/closing your mouth?
___ ___ Have habits such as fingernail biting?
___ ___ Have bleeding gums? For how long?
___________________________
___ ___ Brush your teeth at least once daily?
___ ___ Use dental floss at least once daily?
___ ___ Use a soft toothbrush?
___ ___ Use any other oral hygiene aids?
___ ___ If so, what?_________________
___ ___ Have sensitivity to hot/cold/sweets?
___ ___ Are you satisfied with the appearance
of your teeth?
___ ___ Had prolonged bleeding after tooth extraction?
___ ___ Noticed any shifting of your teeth?
___ ___ Worn braces?
___ ___ Ever had a full mouth series of x-rays? When?
________________________________________
___ ___ Had professional oral hygiene instructions?
___ ___ Had your teeth cleaned in the last year? When?
_________________________________________
___ ___ Ever been told you have periodontal disease?
___ ___ Ever had Periodontal Surgery?
When, where in mouth?_____________________
___ ___ Would loss of your teeth be of great concern to you?
___ ___ Other (please specify)_______________________
__________________________________