Patient medical history

Patient Medical History
Physician______________________________________________ Office Phone___________________________Date of Last Exam_________________
Are you under a physician’s care now?  Yes  No If yes, please explain:________________________________________________
Have you recently been hospitalized?  Yes  No If yes, please explain:________________________________________________
Are you taking any medications, pills, or drugs?
 Yes  No Please list drugs:____________________________________________________
Do you take, or have you taken, Phen-Fen or Redux?  Yes  No
Have you ever taken Fosamax, Boniva, Actonel or any
other medications containing bisphosphonates?  Yes No
Are you on a special diet?
 Yes No
Do you use tobacco?  Yes No
Do you use controlled substances?  Yes No

Women: Are you:
Pregnant/Trying to get pregnant?  Yes  No Taking oral contraceptives?  Yes  No Nursing?  Yes  No
Are you allergic to any of the following?
Aspirin Penicillin Codeine Local Anesthetics Acrylic Metal Latex Sulfa drugs
 Other If yes, please explain:_________________________________________________________________________________________________________________


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

Cold Sores/Fever Blisters Yes No Heart Murmur Congenital Heart Disorder Yes No Heart Pacemaker Patient Dental History
Name of Previous Dentist______________________________________________________________________ Date of Last Exam___________________________
Previous Dentist’s Location____________________________________________________________________ Date of Last Cleaning________________________
Yes No Yes No
1. Do your gums bleed while brushing or flossing?
  14. Have you ever had any prolonged bleeding
2. Are your teeth sensitive to hot or cold liquids/foods?
  following extractions?  
3. Are your teeth sensitive to sweet or sour liquids/foods?
  15. Do you wear dentures or partials?  
4. Do you feel pain to any of your teeth?
  If yes, date of placement____________________________
5. Do you have any sores or lumps in or near your mouth?   16. Do you have frequent headaches?
6. History of any periodontal therapy?   17. Do you clench or grind your teeth?  
7. Do you like your smile?   18. Have you ever experienced any of the following problems
8. Do you snore or have you been told that you snore?   in your jaw?
9. Have you ever received oral hygiene instructions?   Clicking, popping  
10. Have you had any head, neck or jaw injuries?
  Pain (joint, ear, side of face)  
11. Do you bite your lips or cheeks frequently?   Difficulty in opening or closing  
12. Have you ever had any difficult extractions in the past?   Difficulty in chewing  
13. Have you had any orthodontic treatment?  
To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous
to my (or patient’s) health. It is my responsibility to inform the dental office of any changes in medical status.
SIGNATURE OF PATIENT, PARENT OR GUARDIAN__________________________________________________________DATE____________________________

Source: http://dentalboutique.us/forms_policies/Patient%20Medical%20History%20Form.pdf