Dental Patient Information Form Page 2
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2MIDWESTERN DENTAL
PATIENT DENTAL HISTORY
PREVIOUS DENTIST:
DATE OF LAST DENTAL EXAM:
YES
( ) Are you or have you recently been experiencing pain in your mouth or face?
( ) Do you have any dental condition(s) which you believe requires immediate attention today?
( ) Have you experienced an unusual reaction to a local anesthetic (novocaine)?
( ) Have you ever had abnormal bleeding associated with previous extractions, surgery or accidents?
DO YOU HAVE OR USE ANY OF THE FOLLOWING (INDICATE WITH X)
YES
YES
YES
( ) Teeth sensitive to cold, heat
( ) Frequent blisters on lips
( ) Oral habits (fingernail / check biting)
sweets or pressure
or mouth (cold sores)
( ) Cigarette, pipe or cigar smoking
( ) Bleeding Gums; How Long ____________
( ) Swelling or lumps in mouth
( ) Unfavorable dental experience
( ) Food Impaction
( ) Pain around ear
( ) Jaw clicking / popping
( ) Unpleasant taste
( ) Headaches
( ) TMJ / Jaw problems
( ) Bad breath
( ) Orthodontic treatment
( ) Clenching or grinding of teeth
( ) Periodontial treatment (gums)
MEDICAL HISTORY
PHYSICIAN’S NAME:
CITY:
DATE OF LAST PHYSICAL EXAM:
YES
( ) Has there been any recent change in your general health?
( ) Do you take any medications, drugs or pills (including birth control pills)? If yes, please list: ______________________________________
( ) Are you being treated for any condition by a physician now? If yes, please explain: ______________________________________________
( ) Have you been hospitalized during the past two years? If yes, please explain: __________________________________________________
( ) ARE THERE ANY MEDICATIONS THAT YOU CANNOT TAKE OR ARE ALLERGIC TO OR HAVE HAD A REACTION TO?
( ) PENICILLIN
( ) CODEINE
( ) NOVACAINE
( ) ASPIRIN
( ) ANESTHETICS
( ) LATEX
( ) OTHER __________________
( ) Have you ever had a General Anesthetic? List any problems: ______________________________________________________________
( ) FOR WOMEN: Are you pregnant? If so, how many months? _________ months
Are you breast feeding? ( ) Yes
( ) No
INDICATE WITH (X) ONLY IF YOU HAVE OR HAVE HAD ANY OF THE FOLLOWING:
YES
YES
YES
( ) Rheumatic Fever
( ) Shortness of Breath
( ) Eye Disorders
( ) Heart Murmur
( ) Sickle Cell Trait or Anemia
( ) Muscular Disease
( ) Heart Attack
( ) Bleeding Disorder
( ) Head / Spinal Injury
( ) Cardiac Pacemaker
( ) Diabetes
( ) Artificial Joint
( ) Artificial Heart Valve
( ) Liver Disease
( ) Organ Transplant
( ) Congenital Heart Disease
( ) Dialysis
( ) Hormone Disorder
( ) Mitral Valve Prolapse
( ) Hepatitis __________
( ) Genetic Disorder
( ) Angina / Chest Pain
( ) Tuberculosis
( ) Steroid Use
( ) High / Low Blood Pressure
( ) Venereal Disease
( ) Radiation Therapy
( ) Stroke
( ) AIDS (HIV)
( ) Cancer Therapy
( ) Ankle Swelling
( ) Ulcers or Colitis
( ) Hayfever
( ) Tire Very Easily
( ) Epilepsy or Seizures
( ) Asthma
( ) Fainting Spells
( ) Long Disease
( ) Arthritis
( ) Sinus Trouble
( ) Thyroid
( ) Other _______________________
YES NO
( )
( )
Is there any health information which was not asked which may influence dental treatment? If yes, please explain ______________
TO THE BEST OF MY KNOWLEDGE THE FOREGOING QUESTIONS HAVE BEEN ACCURATELY ANSWERED.
______________________________________________
__________________________________
SIGNATURE OF PATIENT / PARENT
REVIEWED BY D.D.S.
Note: Any change in your health status should be reported to this office at the earliest possible time.
PERMISSION TO RELEASE HEALTH INFORMATION: I grant the right to the dentist to release health information about me and information about
my dental treatment to third party payors and / or other health practitioners.
________________________________________________
________________
________________________________________
SIGNATURE OF PERSON COMPLETING THIS FORM
DATE
IF OTHER THAN PATIENT, INDICATE RELATIONSHIP
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Parent category: Medical