Medical Dental History Form
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1
2MEDICAL DENTAL HISTORY FORM
Patient Name:_________________________
Medical Clinic
________________
Patient ID
Physician_____________________________
#: _____________________________
Allergies to:
PreMed required? Yes No
Latex:
Yes
No
Medications ___________________________
Reason: ___________________________
Other ___________________________
Type: ___________________ Dosage:
Current Medications (Prescription, Over the counter and Herbal)
MEDICATION
DOSAGE
FREQUENCY
MEDICATION
DOSAGE
FREQUENCY
PAST AND CURRENT MEDICAL CONDITIONS (mark all that apply)
Yes
Yes
8 Under physician's care?
37 Sinus trouble?
Details:
38 Cancer?
Year Diagnosed:
9 Hospitalization/operation(s) in last 5 years?
39 Oral Cancer?
Year Diagnosed:
Details:
40 Family History of Head/Neck Cancer?
10 Head/neck/mouth injuries?
41 Radiation Treatment to Head/Neck?
11 Women: pregnant?
42 Chemotherapy?
12 Women: nursing?
43 Kidney Disease?
13 Women: oral contraceptives?
44 Dialysis?
14 Heart trouble/disease?
45 Eating Disorder?
15 Rheumatic fever?
46 Stomach:
reflux?
ulcer?
16 Past use of Fenphen?
47 Immunological disease?
17 Heart murmur?
48 Sjogrens Disease?
18 Mitral valve prolapse?
49 Fibromylagia?
19 Heart surgery?
50 Other autoimmune disease (lupus, pemphigus)?
20 Artificial heart valves?
51 Arthritis or other joint disorders?
21 Pacemaker?
52 Diabetes? Type:
Controlled? Y N
22 Indwelling defibrillator?
53 Headaches?
23 Artificial joints?
54 Depression: Diagnosed?
24 History of Organ Transplant?
55 Other Psychiatric Disorders?
25 High blood pressure?
BP:
/
56 Neurologic Disease?
26 Stroke?
57 Convulsions?
27 Bleeding problem?
58 Epilepsy/seizures?
28 Hemophilia?
59 Cerebral Palsy?
29 Anemia?
60 Fainting/dizziness?
30 Leukemia?
61 Sexually Transmitted Disease (STD)?
31 Lung disease?
62 History of Human Papilloma Virus 16 or 18
32 Emphysema?
63 AIDS/HIV positive?
33 Shortness of Breath?
64 Alcohol or chemical dependency?
34 Asthma?
65 Hepatitis?
35 Sleep Apnea?
66 Thyroid disease?
36 Tuberculosis?
67 Glaucoma?
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