Dental Health Questionnaire
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1DENTAL HEALTH QUESTIONNAIRE
Personal Data - Privacy Act of 1974
ARE YOU IN FLIGHT STATUS? . . .
YES
NO
OCCUPATION/JOB:
ARE YOU PRESENTLY ILL OR UNDER THE CARE OF A PHYSICIAN? . . . . YES
NO
IF YES, PLEASE DESCRIBE:
_____________________________________________________________________________________________________
ALLERGIES (including medication, Latex, jewelry, metal, etc.):
___________________________________________________________________________
CURRENT MEDICATIONS:
_______________________________________________________________________________________________________
(including aspirin, over-the-counter medications, etc.):
_______________________________________________________________________________
HISTORY OF HOSPITALIZATIONS:
________________________________________________________________________________________________
ANY FAMILY HISTORY OF:
Heart Disease
Cancer
Diabetes
Seizures
HAVE YOU EVER HAD OR DO YOU NOW HAVE:
Don't
Don't
Don't
Yes
No
Yes
No
Yes
No
Know
Know
Know
Epilepsy or Seizures
Hemophilia
Ulcers
Fainting or dizziness
Bruise or bleed easily
Kidney problems
Anxiety reaction
Heart problems/Angina
Venereal disease
Stroke
Hypertension
Diabetes
Glaucoma
Rheumatic fever
Thyroid disease
Cold Sores (Herpes)
Heart murmur
HIV/AIDS
Persistent cough
Mitrol valve prolapse
Arthritis
Emphysema
Congenital heart lesions
Painful joints (incl. jaw)
TB/PPD positive
Heart surgery
Prosthetic joint
Asthma
Prosthetic heart valve
Hives
Hay Fever
Pacemaker
Steroid medication
Sinus problems
Blood transfusions
Drug addiction
Anemia
Liver disease
Alcoholism
Sickle cell disease
Yellow jaundice
Unexplained weight change
G-6-PD deficiency
Hepatitis - type:
Cancer/radiation therapy
HAVE YOU EVER BEEN TOLD THAT YOU SHOULD NOT DONATE BLOOD?
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
HAVE YOU EVER BEEN TOLD THAT YOU NEED ANTIBIOTICS BEFORE DENTAL TREATMENT? - - - - - - - - - - - - - - - - - - - - - -
FEMALES: Are you taking birth control pills?
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
Are you or might you be pregnant?
Estimated delivery:
DO YOU HAVE ANY DISEASE, CONDITION, OR PROBLEM NOT LISTED ABOVE? Please describe:
Patient's signature
Date
SUMMARY OF PERTINENT FINDINGS / RECOMMENDED TREATMENT MODIFICATIONS (Dentist's use only)
B/P:
WELLNESS SCREEN:
Tobacco use
Exercise
Diet/nutrition
Alcohol use
Stress
Seat belt use
Dental Officer's Signature
Date
PATIENT'S NAME
(Last, First, MI)
SEX
PATIENT'S IDENTIFICATION
RELATIONSHIP TO SPONSOR
SERVICE
DATE OF BIRTH
SPONSOR'S NAME
RANK/GRADE
ORGANIZATION/COMMAND
SSN
PHONE #:
DAY
EVENING
U.S. D E P T. OF HOMELAND SECURITY, U S C G, C G-5605 (6-04)
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