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Medical history

Today’s Date ___________ Account # ____________ NAME _____________________________
1. Are you having any dental problems at this time?……………………………………………….…O Yes O No
2. Do you feel very nervous about having dental treatment?………………………………………. O Yes O No
3. When was the last time you saw a dentist?_______________ For what?___________________
4. Have you been a patient in the hospital during the past two years?……………………………. O Yes O No
If yes, for what reason? ____________________________________________________________ 5. Have you been under the care of a medical doctor during the past two years?………………… O Yes O No
If yes, for what reason?___________________________________________________________
6. What is the name of your primary care physician?_______________________________________
7. Are you allergic to (i.e., itching, rash, swelling of hands, feet or eyes) or made sick by penicillin, aspirin,
Codeine, LATEX or any drugs or medications?……………………………………………… O Yes O No
If yes, please list:________________________________________________________________________
8. When you walk up stairs or take a walk, do you ever have to stop because of pain in your chest, shortness of
breath, or because you are very tired?…………………………………………………………. O Yes O No
9. Do you ever wake up from sleep short of breath?…………………………………………… O Yes O No
10. Has your medical doctor ever said you have cancer or a tumor?……………………………… O Yes O No
11. Are you currently taking or have you ever taken any of the following biphosphonate medications either orally or
by IV? Fosamax (Alendronate), Boniva (Ibandronate), Actonel (Risedronate), Zometa (zoledronate), Aredia (Pamidronate), Skelid (Tiludronate), Didronel (Etidronate). If yes, For how long did you/have you take(n) the medication? ______________________
12. Do you have or have you ever had any of the following diseases, medical conditions, or procedures?

Y N Heart Attack/ Stroke Y N Thyroid Problems
Y N HIV+/AIDS
Y N Heart Surgery/ Pacemaker/Stent Y N Kidney Problems
Y N Hepatitis A, B, or C
Y N Angina Pectoris (chest pain) Y N Liver Problems
Y N Alcohol/ drug abuse
Y N High/Low Blood Pressure Y N Fainting/ Epilepsy/ Seizures Y N Venereal Disease
Y N Artificial Heart Valves Y N Respiratory problems Y N Tuberculosis (TB)
Y N Congenital Heart Conditions Y N Sinus Trouble Y N Allergies/Hives/Hay fever
Y N History of Endocarditis Y N Stomach problems/ ulcers Y N Arthritis/ Rheumatism
Y N Heart transplant Y N GERD/ Acid Reflux
Y N Neck/ Back Problems
Y N Rheumatic Fever Y N Psychiatric/ Anxiety Problems Y N Cold sores/ fever blisters
Y N Artificial Joint Y N Bleeding problems/ hemophilia Y N Emphysema/ COPD
Y N Cancer/ tumor
Y N Anemia
Y N Asthma
Y N Leukemia
Y N Blood transfusion
Y N Cortisone Medication
Y N Chemotherapy
Y N Diabetes/ Hypoglycemia Y N Adrenal Disease
Y N Radiation therapy
Y N Glaucoma
13. Women: Are you pregnant? O Yes O No If yes, what month are you due?_________
Are you taking birth control pills or depo shot?……………………………………………… O Yes O No
14. Do you have any disease, condition or problem not listed?………………………………… O Yes O No
If yes, what?______________________________________________________________
15. List all medications you are taking at this time (including vitamins, natural remedies, and over the counter
medications like Aspirin, Tylenol, or Ibuprofen) ______________________________________________________________________________________________ ______________________________________________________________________________________________ _____________________________________________________________________________________________ 16. List any medical problems you are being treated for currently.________________________________________ _____________________________________________________________________________________________
17. How much soda pop do you drink per day?__________
18 . Do you use or have you EVER used recreational drugs? (I.e. marijuana, cocaine, etc.)……. O Yes O No
19. Do you use any tobacco products?. O Yes O No
If yes cigarettes? _________, chew?______, pipe?______ How much? _______, For how long? ____________
Are you interested in quitting?. O Yes O No

Source: http://www.flinthillshealth.org/forms/dental/Medical%20History-English.pdf

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