Client Medical History Form

ADVERTISEMENT

Wood Family Dentistry
Client Medical History Form
We are a health centered dental practice. Thus, we are concerned with your total well-being, not just your oral health. An essential part of our
approach is a thorough health history. Please ll out the health questionnaire below completely – even if some of the questions may not seem
relevant to your dental health. Thank you!
What are your hobbies or special interests? (i.e.: sports, self-improvement, education) _______________________________________________
Please check either Y (yes) or N (no) as applicable.
Do you have, or have you ever had any of the following:
Hypoglycemia, Diabetes
Yes
No
Prosthetic Valves, Joints, or Implants
Yes
No
 Yes  No
 Yes  No
 Yes  No
 Yes  No
 Yes  No
 Yes  No
Yes
No
 Yes  No
 Yes  No
Yes
No
Heart Attack or Heart Trouble
Stroke
Hay Fever, Asthma, Allergies
Yes
No
Heart Murmur, Mitral Valve Prolapse
Yes
No
 Yes  No
 Yes  No
 Yes  No
 Yes  No
 Yes  No
 Yes  No
Yes
No
 Yes  No
 Yes  No
Yes
No
High Blood Pressure
Rheumatic Fever
Circulatory Problems
 Yes  No
 Yes  No
Yes
No
Anemia, Blood Disorder
 Yes  No
 Yes  No
Yes
No
 Yes  No
 Yes  No
Yes
No
 Yes  No
 Yes  No
Yes
No
Hepatitis, Jaundice
Excessive Bleeding
Lung Problems, Tuberculosis
Yes
No
Fainting, Blackouts
Yes
No
 Yes  No
 Yes  No
 Yes  No
 Yes  No
 Yes  No
 Yes  No
 Yes  No
 Yes  No
Epilepsy, Seizures
Yes
No
Nervous Disorders
Yes
No
Blood Transfusion
 Yes  No
 Yes  No
Yes
No
Headaches, Migraines
 Yes  No
 Yes  No
Yes
No
 Yes  No
 Yes  No
 Yes  No
 Yes  No
Facial or Head Injuries
Yes
No
Kidney Problems
Yes
No
Radiation, Chemotherapy
Glaucoma, Eye Problems
 Yes  No
 Yes  No
Yes
No
 Yes  No
 Yes  No
Yes
No
 Yes  No
 Yes  No
Yes
No
 Yes  No
 Yes  No
Yes
No
Malignancies, Cancer
Ulcers, Digestive Problems
Sinus Problems
Yes
No
History of Eating Disorders
Yes
No
 Yes  No
 Yes  No
 Yes  No
 Yes  No
 Yes  No
 Yes  No
 Yes  No
 Yes  No
AIDS, ARC
Yes
No
Are you pregnant now?
Yes
No
HIV Positive
Are you nursing or taking birth control pills?
 Yes  No
 Yes  No
Yes
No
 Yes  No
 Yes  No
Yes
No
 Yes  No
 Yes  No
 Yes  No
 Yes  No
Arthritis or Rheumatism
Yes
No
Venereal Diseases
Yes
No
Name of physician ______________________________ Phone_________________________ Date of last physical ____________________
 Yes  No
 Yes  No
Have you been hospitalized in the last two years?
If yes, please explain. _______________________________________
Yes
No
 Yes  No
 Yes  No
Yes
No
Do you consume alcohol or use tobacco?
In what quantities? ________________________________________
Have you had unfavorable reactions to any of the following? (Please check all that apply)
Aspirin
Latex
Codeine
Anesthetics
Xylocaine
Novocaine
Sedatives
Penicillin
Erythromycin
Other Antibiotics
Other Drugs ________________________________________________________________________________________________________
Please list any drugs currently being taken _______________________________________________________________________________
Reason for this dental visit ____________________________________________________________________________________________
Date of last dental visit_______________________________________ What was done at that time? ________________________________
Have you ever been treated by a periodontist, orthodontist, or endodontist?
 Yes  No
 Yes  No
Yes
No
If yes, please explain ______________________
____________________________________________________________________________ Date of last x-rays ______________________
Are you happy with the appearance of your teeth?
 Yes  No
 Yes  No
Yes
No
Have you noticed any of the following?
Teeth tender to chew on
 Yes  No
 Yes  No
Yes
No
Recurring sore in or around the mouth
 Yes  No
 Yes  No
Yes
No
Discomfort in face, head, neck, jaw
 Yes  No
 Yes  No
Yes
No
Jaw clicking or popping
 Yes  No
 Yes  No
Yes
No
Food caught between teeth
 Yes  No
 Yes  No
Yes
No
Loose teeth
 Yes  No
 Yes  No
Yes
No
Bleeding or sore gums
 Yes  No
 Yes  No
Yes
No
Swelling, lumps in mouth
 Yes  No
 Yes  No
Yes
No
Yes
No
Yes
No
Sensitivity to sweets, hot or cold
 Yes  No
 Yes  No
Do you need nitrous, oral or IV sedation for dental visits?
 Yes  No
 Yes  No
Have you had any problems with previous dental treatment?
 Yes  No
 Yes  No
Yes
No
If so, please explain ___________________________________________________________________________________________________
The information above is correct to the best of my knowledge.
Signature _____________________________________________________________________ Date _________________________________

ADVERTISEMENT

00 votes

Related Articles

Top 20 Happy Easter Cards And Gift Tags To Download For Free
Top Ten Easter Arts And Crafts Activities For Your Kids
Free Easter Coloring Pages And Easter Printables For Your Kids

Related forms

Client Medical Clearance Form Client Medical Clearance Form Medical
Medical History Form/historial Medico Medical History Form/historial Medico Medical
Client Health History Form Georgian College Client Health History Form Georgian College Medical
Medical History Form - Oregon Medical Group Medical History Form - Oregon Medical Group Medical
Form 10 - 0804: Dental And Medical History Form Form 10 - 0804: Dental And Medical History Form Medical
Form Co/dv-124 - Driver Medical History Form Form Co/dv-124 - Driver Medical History Form Legal
Form Yp-0878 Medical History Form Form Yp-0878 Medical History Form Medical
Form Adph-hs-86 - Request To Place A Contact Preference And Medical History Form With The Child's Original Birth Certificate Form Adph-hs-86 - Request To Place A Contact Preference And Medical History Form With The Child's Original Birth Certificate Legal
Medical History Form Medical History Form Medical
Medication History Form Medication History Form Medical

Related Categories

Parent category: Medical
Download
Go