Medical History Form Page 2
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2j. AIDS or HIV infection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes
No
k. Thyroid problems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes
No
l. Respiratory problems, emphysema, bronchitis, etc. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..
Yes
No
m. Arthritis or painful swollen joints . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes
No
n. Stomach ulcers or hyperacidity . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . .
Yes
No
o. Kidney trouble . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes
No
p. Tuberculosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. .
Yes
No
q. Persistent cough or cough that produces blood . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes
No
r. Persistent swollen glands in neck . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes
No
s. Low blood pressure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes
No
t. Sexually transmitted disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes
No
u. Epilepsy or other neurological disease . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes
No
v. Problems with mental health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes
No
w. Cancer . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes
No
x. Problems of the immune system . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes
No
y. Other _____________________________________________________________________
9. Have you had any serious trouble associated with any previous dental treatment? . . . . . . . . . . . .
Yes
No
If so, explain___________________________________________________________________
10. Do you have any disease, condition, or problem not listed that you think I should know about?
Yes
No
If so, explain__________________________________________________________________
11. Are you wearing contact lenses? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes
No
12. Are you wearing removable dental appliances?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes
No
13. Do you have any bleeding problems? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes
No
14. Are you pregnant? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes
No
15. Are you nursing? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes
No
16. Are you taking birth control pills? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes
No
17. Are you now taking, or have you ever taken any of the following drugs for osteoporosis or other
Yes
No
Fosamax, Actonel, Boniva, Aretia, Zometa, Didronel, Skelid, Reclast
bone disease:
?
Chief Dental Complaint
______________________________________________________________________________
I certify that I have read and understand the above. I acknowledge that my questions, if any, about the
inquiries set forth above have been answered to my satisfaction. I will not hold my dentist, or any other
member of his/her staff, responsible for any errors or omissions that I may have made in the completion of
this form.
_____________________________________
___________
(Signature of Patient/Legal Representative)
(Date)
For completion by the dentist.
Comments on patient interview concerning medical history: ___________________________________
Significant findings from questionnaire or oral interview: ______________________________________
Dental management considerations:_______________________________________________________
______________________________________________
________________________
( Signature of Dentist)
(Date)
Medical history updated:______________
_____________________________________
(Date)
(Patient’s Signature)
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