Medical-Dental History
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1
2MEDICAL-DENTAL HISTORY
Name (Mr., Ms., Mrs.): ___________________________________
What should we call you? ____________________________________
Address: _______________________________________________
Date of birth: ______________________________________________
City: ____________________________ Zip Code: _____________
Age: _____________________________________________________
Home Phone: ___________________________________________
Occupation: _______________________________________________
Cell Phone: ____________________________________________
Employer: ________________________________________________
Work Phone: ___________________________________________
E-Mail: __________________________________________________
Referred by: ____________________________________________
Social Security Number: _____________________________________
Name of Dentist:_________________________________________
Hobbies: _________________________________________________
Name of Family Physician: ________________________________
Dental Insurance:
Yes
No
Name of Cardiologist: ____________________________________
Emergency Contact: ______________________________________
Name of Pain Management Physician: _______________________
Where have you heard about us? Please check all that apply:
Television
Friend
Internet
Sign
Radio
Newspaper
Referring Dentist: ______________________________________________________________________________________________
1. Are you currently under the care of a physician?
Yes
No
2. Please list dates and reasons for hospitalizations__________________________________________________________________________
_________________________________________________________________________________________________________________
3. Please list allergies to drugs or medications______________________________________________________________________________
_________________________________________________________________________________________________________________
Have you ever been treated for the following conditions:
4. Rheumatic fever, rheumatic heart disease, heart murmur or congenital heart disease? If yes, please specify.__________________________
________________________________________________________________________________________________________________
5. Heart trouble, heart attack, angina, heart surgery, a pacemaker, or irregular beats? If yes, please specify. ____________________________
________________________________________________________________________________________________________________
Have you ever or are you currently been treated for the following conditions:
6. Excessive bleeding:
Yes
No
List medications: _________________________________________________________________
7. Breathing problems, asthma, tuberculosis, hay fever:
Yes
No
List medications: _______________________________________
8. Cancer, x-ray treatment, or chemotherapy:
Yes
No
List medications: _______________________________________________
9. Hepatitis, jaundice, or liver disease:
Yes
No
List medications: _____________________________________________________
10. Kidney problems or renal dialysis:
Yes
No
List medications: _____________________________________________________
11. Venereal disease, STD's or AIDS:
Yes
No
List medications: ______________________________________________________
12. A stroke, convulsions, or fainting spells:
Yes
No
List medications: ________________________________________________
13. Tumors or growths:
Yes
No
List medications: _________________________________________________________________
14. Arthritis or rheumatism:
Yes
No
List medications: _____________________________________________________________
15. High cholesterol:
Yes
No
List medications: ___________________________________________________________________
16. High blood pressure:
Yes
No
List medications: ________________________________________________________________
17. Diabetes:
Yes
No
List medications: _________________________________________________________________________
If yes:
Type 1
Type 2
When was your last AIC test result: ____________ How often are you tested: ______________
Do you take any of the following:
18. Pain medications:
Yes
No
List medications: __________________________________________________________________
19. Anxiety or mind altering medications:
Yes
No
List medications: __________________________________________________
20. Sleep medications:
Yes
No
List medications: _________________________________________________________________
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Parent category: Medical