Dental and medical history

Please fill out your dental and medical histories to the best of your ability. This information is confidential!

DENTAL HISTORY

Are you anxious/nervous about receiving dental treatment? Yes No Somewhat Have you had a bad experience with dental treatment? Yes No Are you happy with your smile? Yes No Somewhat  Food gets stuck between teeth  Dry mouth MEDICAL HISTORY

Do you see a physician regularly? Yes No If yes, for what? Have you ever had any serious illness or operation? Yes No Have you ever been hospitalized? Yes No Have you ever had blood transfusions? Yes No Reason: Women: Are you pregnant? Yes No Possibly Take birth control pills? Yes No Nursing? Yes No Check all problems/treatments you have or have had:
Yes No Anemia
Yes No Diabetes
Yes No Jaw pain
Yes No Sinus trouble
Yes No Arthritis, Rheumatism Yes No Epilepsy
Yes No Kidney Disease
Yes No Skin rash
Yes No Artificial Heart Valves Yes No Fainting/dizziness
Yes No Liver Disease
Yes No Special diet
Yes No Artificial Joints
Yes No Gastric Bypass
Yes No Mitral Valve Prolapse Yes No Stomach Ulcer
Yes No Asthma
Yes No Glaucoma
Yes No Osteoporosis
Yes No Intestinal Ulcer
Yes No Back problems
Yes No Headaches
Yes No Pacemaker
Yes No Stroke
Yes No Bleeding problems
Yes No Heart murmur
Yes No Panic/anxiety
Yes No Thyroid Problems
Yes No Blood disease
Yes No Heart problems
Yes No Tobacco/smoking
Yes No Tonsillitis
Yes No Cancer
Yes No Hemophilia
Yes No Psychiatric care
Yes No Tuberculosis
Yes No Chemical dependency Yes No Hepatitis
Yes No Radiation treatment Yes No Tumor/growth
Yes No Chemotherapy
Yes No Herpes
Yes No Respiratory disease
Yes No Circulatory problems Yes No High blood pressure Yes No Scarlet fever
Yes No Cortisone treatments Yes No HIV/AIDS
Yes No Shortness of breath
Yes No Cough blood
Yes No Rheumatic fever
List all prescription medications you are taking: List all over-the-counter medications and nutritional supplements you are taking: The information on this form is true and correct as of the date indicated below to the best of my knowledge. I understand that not reporting any conditions/medications/allergies may complicate my treatment, and may pose a serious health risk to me, and to the healthcare team. Signature (guardian, if patient under 18)
MEDICAL HISTORY UPDATE FORM
Date: ________________

Has there been any change in your health since your last dental appointment?
Are you taking any kind of medications at this time? Yes No No Change Since Last Visit
MEDICAL HISTORY UPDATE FORM
Date: ________________

Has there been any change in your health since your last dental appointment?
Are you taking any kind of medications at this time? Yes No No Change Since Last Visit

MEDICAL HISTORY UPDATE FORM
Date: ________________

Has there been any change in your health since your last dental appointment?
Are you taking any kind of medications at this time? Yes No No Change Since Last Visit

MEDICAL HISTORY UPDATE FORM
Date: ________________

Has there been any change in your health since your last dental appointment?
Are you taking any kind of medications at this time? Yes No No Change Since Last Visit

Source: http://www.valleyvillagedentist.com/docs/Health-History.pdf