Patient Medical History Form
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1B. Ardi Pribadi, DDS, PS
430 N. West Ave Suite 1, Arlington, WA, 98223
(360) 474-9163
PATIENT MEDICAL HISTORY FORM
Your comfort and good dental health are dependent upon an accurate knowledge of your medical health. Many medical situations can affect, or be affected
by, procedures or drugs used in dentistry. Therefore, please complete the following carefully:
HAVE YOU EVER HAD ANY OF THE FOLLOWING CONDITIONS? (PLEASE CIRCLE)
Heart Disease
Heart Murmmer
Bruise Easily
Asthma/Hay
Liver Disease
Fainting/Dizziness
Drug Addiction
Unexplained
Total Joint
Fever
weight gain/loss
Replacement
Angina Pectoris
Congenital
Prolonged
Emphysema
Jaundice (other
HIV +
Psychiatric
Tonsilitis
Osteoporosis
Heart Disease
Bleeding
than birth)
Treatment
Chest Pains
Rheumatic
Anemia
Tuberculosis
Hepatitis
AIDS
Cancer
Chronic Sinus
Fosamax use
Fever
(TB)
Problems
High Blood
Stroke
Blood
Diabetes
Thyroid Disease
Cold Sores
Radiation
Low Blood
Dry Mouth
Pressure
Transfusion
Therapy
Pressure
Shortness of
Hemophilia
Sickle Cell
Ulcers
Glaucoma
Genital Herpes
Chemotherapy
Coumadin
Halitosis (Bad
breath
Disease
(Wafarin) use
Breath)
Swollen Ankles
Artificial Heart
Arthritis
Kidney Trouble
Seizures
Venereal Disease
Implant
Blood Thinners
Staph Infection
Valve
Prosthesis
PLEASE ANSWER EACH QUESTION AS DETAILED AS POSSIBLE:
1.
DO YOU CURRENTLY HAVE ANY SERIOUS MEDICAL CONDITIONS, FOR WHICH YOU ARE BEING TREATED?____________________________________________________
_________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________
2.
ARE YOU ALLERGIC TO ANY MEDICATIONS OR MATERIALS (INCLUDING LATEX, PENICILLIN, CODEINE, ASPIRIN, LIDOCAINE, NOVACAINE)?_________________________
__________________________________________________________________________________________________________________________________________
3.
HAVE YOU EXPERIENCED ANY COMPLICATIONS FOLLOWING A DENTAL TREATMENT?____________________________________________________________________
_________________________________________________________________________________________________________________________________________
4.
DO YOU HAVE ANY DISEASES NOT CIRCLED ABOVE?_______________________________________________________________________________________________
5.
HAVE YOU BEEN TOLD YOU WERE NOT ELIGIBLE TO BE A BLOOD DONOR?_____________________________________________________________________________
6.
HAVE YOU BEEN TOLD TO TAKE ANTIBIOTICS PRIOR TO DENTAL CARE?________________________________________________________________________________
7.
PLEASE LIST ALL MEDICATIONS THAT YOU ARE CURRENTLY TAKING. IF YOU HAVE A COPY OF YOUR LIST OF MEDICATIONS, PLEASE ALLOW US TO COPY IT FOR YOUR
FILE:______________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________
8.
(WOMEN ONLY, PLEASE CIRCLE )
ST
ND
RD
1. ARE YOU PREGNANT?
YES
NO
IF YES, WHAT TRIMESTER:
1
2
3
2. ARE YOU TAKING HORMONE MEDICATIONS?
YES
NO
3. ARE YOU TAKING BIRTH CONTROL PILLS?
YES
NO
4. ARE YOU TAKING FERTILITY MEDICATIONS?
YES
NO
9.
HOW LONG HAS IT BEEN SINCE YOUR LAST DENTAL EXAM AND CLEANING?_____________________________________________________________
10. DO YOU HAVE ANY FEAR OF THE DENTIST?___________IF YES, (PLEASE CIRCLE)
MILD
MODERATE
SEVERE
NO PAIN 1 2 3 4 5 6 7 8 9 10 SEVERE PAIN
11. DO YOU HAVE ANY DENTAL PAIN RIGHT NOW?_______IF YES, (PLEASE CIRCLE)
PLEASE DESCRIBE THE PAIN (CIRCLE): THROBBING
HOT/COLD SENSITIVITY
PRESSURE
SWELLING/LUMP
ULCER
CHEWING PAIN
WHEN DID THE PAIN FIRST BEGAN?____________________ IS THE PAIN GETTING WORSE?__________ IS THE PAIN CONSTANT?__________ SPONTANEOUS?_________
12. HOW OFTEN DO YOU BRUSH YOUR TEETH? (PLEASE CIRCLE)
NOT DAILY
DAILY
>2X DAILY
FLOSS? (PLEASE CIRCLE)
NOT DAILY
DAILY
>2X DAILY
13. DO YOU USE ANY TOBACCO PRODUCT?___________IF YES, (PLEASE CIRCLE)
SMOKELESS
CIGARS
CIGARETTES
HOW OFTEN PER DAY?___________________
I HEREBY CERTIFY THAT THE ABOVE INFORMATION IS TRUE AND CORRECT:
NAME (PRINT):____________________________________________________________________________________________ DATE_____________________________________
SIGNATURE:___________________________________________________________________________________________
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