Medical history 2006 wrs v5.xls

Medical History
Patient Name ______________________________
WELCOME, Please take the time to complete this form with your current medical information. You, and your
families medical history will influence your susceptibility to certain dental conditions. The following information
should be as complete and accurate as possible as we use it to select the most appropriate dental care for you.
Please inform us of any changes to your medical history in the future.
Physician's Name _________________________________Physician's Address _________________________________Date of your last medical physical:__________ Are you currently under the care of a physician? Y / N Why?____________________________________________________________________________________________Please check any of the following conditions that you have or have had in the past: ______ Abnormal Bleeding
______ Hepatitis, Type:
______ Anemia/Blood disorders
______ Herpes/Cold Sores/Shingles
______ Any heart problems
______ Kidney/Liver Problems
______ Arthritis/Rheumatism
______ Mental/Emotional Disorders
______ Artificial Heart Valve Implant
______ Nervous Problems
______ Asthma/Hay fever
______ Organ Transplant, Type:
______ Blood Pressure Problems: High / Low
______ Osteoporosis
______ Cancer, Type:
______ Prosthetic Joint Replacement Date:
______ Difficulty Breathing
______ Radiation or Chemotherapy Why:
______ Epilepsy or Seizures
______ Rheumatic Fever
______ Fainting or Dizzy Spells
______ Sinus Problems
______ Frequent Headaches, shoulder or neck aches
______ Stomach Problems
______ Glaucoma or light sensitivity
______ Stroke
______ Heart murmur
______ Tested Positive for HIV
______ Diabetes: Type 1 or Type 2
______ Thyroid: Hypothyroid/Hyperthyroid
Date Diagnosed_______________ Controlled or Uncontrolled? By Medication or Diet? Have you ever taken Bisphosphonates such as Actonel, Boniva, Didronel, or Fosamax? Y /N If yes, what:____________Have you ever taken any prescription weight loss products? Y / N If yes, what:_________________________________Have you ever had a serious illness or major surgery not listed above? Y / N If yes, please explain: ________________ ___________________________________________________________________________________Is there a family history of Diabetes, Heart Disease, Oral Cancer, or Periodontal Disease? Y / N If yes, please explain: ___________________________________________________________________________________
Would you describe your stress level as high, average, or low? Circle one.
Do you smoke, chew, use snuff, or any other forms of tobacco? Y / N Circle those that apply.
How long have you used tobacco? ________________________ How much do you use? ________________________
Have you ever quit or thought about quitting? _________________ Are you interested in quitting?_________________
Please list any medications you are currently taking,
Yes / No List All Allergies
Include prescription and non-prescription: □ □ Aspirin
□ □ Codeine
□ □ Dental Anesthetics
□ □ Erythromycin
□ □ Jewelry or metals
□ □ Latex
□ □ Penicillin
□ □ Sulfa
Other:___________________________________ List any health related substances you take routinely.
Include any vitamins, supplements, or natural products.
If female, please answer the following:
Are you taking Birth Control Pills? Y/ N
Are you pregnant? Y / N If Yes, # of weeks_____
Are you nursing? Y / N
I certify that the above information is complete and accurate.
Patient/Guardian Signature___________________________________________________ Date:___________________Dentist's Initials____________________________________________________________ Date:___________________ 2006 Dental Dynamix, LLC; To Reorder Call: 515-577-2929

Source: http://www.skariedental.com/PDF/History.pdf