Microsoft word - patient dental history 2013.doc

Patient Information
Last, First MI (Preferred Name) Gender: _______ Family Status: Preferred appointment times: Morning Afternoon Any Time M T W T F Emergency Contact Person:_______________________________ Relation to Patient:__________________________ Phone Number:_________________________________________ Health Information
Please Note: All of the following information is needed to allow us to treat you safely and will be kept CONFIDENTIAL.

Please check where you receive your medical care:

Doctor’s Office__________________ Primary Care Provider:_________________________ PLEASE CHECK ALL THAT APPLY:
SURGICAL HISTORY
MEDICAL HISTORY
Aortic Stenosis Arthritis/Osteoarthritis COMMON SYMPTOMS
Migraines / Headaches Nausea / Vomiting Neuritis / Neuralgia / Sciatica MEDICATION SPECIFIC QUESTIONS
• Have you ever taken any of the following medications for Osteoporosis, Bone Cancer or Osteoarthritis? Alendronate (Fosamax) Pamidronate (Aredia) Alendronate & Cholecalciferal (Fosamax Plus) Etidronate & Calcium (Calcium Carbonate, Didrocal) Ridedronate & Calcium (Actonel & Calcium) Any Other Bisphosphonate Medication:______________________________________________________________ • Have you ever taken the prescription drugs Flenfluramine, Flenfluramine with Phentermine (fen-phen), dexfenfluramine (Redux or Pondimin) or other weight loss products? No If so, When:_______________________ Did you have a follow up Echocardiogram: • Are you or have you ever taken a Blood Thinning Medication such as Coumadin/Warfarin, Pradaxa, Plavix, Aspirin or Other? • Have You Been on Steroid Therapy in the Last 6 Months? No If so, when:___________ Name of Drug: ____________________ PLEASE LIST ALL CURRENT MEDICATIONS (DOSAGE AND TIME YOU TAKE THEM)
__________________________________ ____________________________________ ___________________________________ __________________________________ ____________________________________ ___________________________________ __________________________________ ____________________________________ ___________________________________ __________________________________ ____________________________________ ___________________________________ PLEASE LIST ALL KNOWN ALLERGIES
Other Drug Allergies:___________________________________________________________________________________ PERSONAL HEALTH HABITS

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Snuff If so, How long have you used? _______ How much do you use each day?______ How long have you drank alcohol? _________ How often do you drink alcohol? _________ Do you think you drink too much? Do you drink any of the following beverages? Tea If so, How often? __________________ No If so, what:_______________ How often: _________________ How long:_____________
When Did You Last Use?_______________________ (It is very important that you are honest about this because it can affect your treatment.)
IMPORTANT ADDITIONAL INFORMATION
• Have you been admitted to a hospital or needed emergency care during the past two years? If yes, please explain: ______________________________________________________________________________________________________ • Are you now under the care of a physician? If yes, please explain:_______________________________________________________ Name of Physician: _______________________________

• Do you have any health problems that need further clarification?
If yes, please explain:_______________________________________________________________________________________________________
______________________________________ ___/___/_____ ___________________________________ ___/___/_____
PATIENT SIGNATURE DATE DDS SIGNATURE DATE
Adult Dental History
Purpose of your Visit: _____________________________________________________________________________ Are you aware of a problem? _______________________________________________________________________ How long since your last dental visit? _________________________________________________________________ Do you clench or grind your teeth? Yes No Have your ever experienced any pain or soreness in the muscles of your face Yes No Or around your ear or jaw click or pop? Are any of your teeth sensitive? Yes No Are you pleased with the appearance of your teeth? Yes No Have you ever had gum treatment or surgery? Yes No Have you had any orthodontic treatment? Yes No Do you have a dental prosthesis (partial or complete denture)? Yes No If YES when was it made? Month _______ Year ________ Are you interested in getting replacements? Yes No Have you had an unpleasant dental experience or is there anything about Yes No Have you ever had to be pre-medicated with antibiotics or sedatives before Yes No dental treatment? Child/Teen Dental History
• Is this your child’s first visit to the dentist? Yes No • If not, how long since their last visit?________________________________ • How often does your child brush their teeth? _________________________ • Does your child suck his/her thumb or fingers? Yes No • Have there been injuries to teeth from falls or blows that could cause chips? Yes No • Has your child had any problem with dental treatment in the past? Yes No • Do you or your child think there is anything wrong with his/her teeth? Yes No I CERTIFY THAT THE ABOVE INFORMATION IS COMPLETE AND ACCURATE ______________________________________ ___/___/_____ ___________________________________ ___/___/_____
PATIENT SIGNATURE DATE DDS SIGNATURE DATE

Source: http://midental.org/wp-content/uploads/2013/06/Patient-Dental-History-Form-2013.pdf