Medical History Form



    1. Are you seeing a physician at the present time for the treatment of a recent or ongoing
    medical condition?

    2. Have you been hospitalized within the last year?

    3. Have you had a serious illness or operation within the last year?

    4. Have you ever had any serious medical trouble associated with any dental experience?

    5. Have you ever been advised to take antibiotics (like penicillin, etc.) before a dental
    appointment?

    Do you now or have you had any of the following diseases or problems?

    Rheumatic fever or rheumatic heart disease

    Infective endocarditis

    Congenital heart defects

    Prosthetic (artificial) heart valves

    Pacemaker?

    High cholesterol

    Shortness of breath?

    Do your ankles swell?

    Do you have chest pain upon exertion?

    Abnormal bleeding or extended clotting time

    Frequent or unexpected nose bleeds

    Have you ever required a blood transfusion?

    Are you HIV positive?

    Do you have any reason to suspect that you have been exposed to the HIV virus

    Hepatitis?

    Diabetes?

    Do you have an artificial joint?

    Have you ever had Tuberculosis (TB)?

    Have you ever had a TB test?

    Do you have a cough that has lasted more than 3 weeks?

    Do you ever cough up blood?

    Have you tested positive for Covid-19

    Cancer?

    Central Line?

    Select Any That Apply

    When was your last complete physical exam with your medical doctor, including blood tests?

    If you are currently taking these medications – prescribed, over-the-counter, herbal. Please
    list name of drug, dose and frequency.

    Antibiotics

    Antidepressants (Prozac, Zoloft, etc.)

    Antihistamines

    Blood Pressure Medicine

    Blood Thinners

    Cortisone (Prednisone, etc.)

    Cholesterol Medication

    Decongestants

    Diuretics (water pills)

    Hormones (birth control pills, estrogen)

    Inhalants (puffer)

    Insulin

    Medicine for Heart Problems

    Muscle Relaxants

    Nitroglycerine

    Pain Medicine (Aspirin, Advil, Tylenol, etc)

    Prescription Pain Medication

    Sleeping Pills

    Thyroid Medicine

    Tranquilizers

    Vitamins

    CBD

    List all names of drugs & dose

    Are you ALLERGIC to any of the following medications (do you get hives, a rash, have trouble
    breathing, etc.):

    Antibiotics (penicillin, tetracycline, etc .)

    Local or topical Dental Anesthetics (novacaine)

    Codeine

    Aspirin

    Barbituates or Sedatives

    Tranquilizers

    Food (Dairy)

    Cortisone (Steroids)

    Latex

    Other

    Do you now or have you ever smoked?

    Do you smoke marijuana / cannabis use?

    Do you chew tobacco?

    Do you drink alcohol?

    Are you currently on hormone replacement therapy?

    Have you ever had an adverse reaction like nausea, dizziness, or feeling “spacey”
    with any drug or medication?

    Do you have any disease, condition or problem not previously listed that you feel we
    should know about?

    Dental History

    Date of last dental/ dental hygiene visit?

    What care did you receive at the last dental visit?

    Do you require complete mouth care or emergency treatment?

    Are you under the care of a dental specialist? (Orthodontist, Endodontist,
    Prosthodontist, Periodontist)

    Have you had any dental problems within the last year with your teeth, gums, jaw,
    chewing?

    Date of last dental/ dental hygiene visit?

    What care did you receive at the last dental visit?

    Do you require complete mouth care or emergency treatment?

    Have you ever had a thorough exam of your mouth including a complete set of
    radiographs (16-20 films)of your jaws and teeth?

    Have you had x-rays in the past two years?

    In order that we may be sensitive to your dental needs, please tell us of any unpleasant
    experiences you may have had related to oral care.

    Patient’s Parent / Guardian Signature



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