Patient Medical History Form printable pdf download

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B A N K A I D E N T A L

Name:

__________________________

P A T I E N T H E A L T H H I S T O R Y

_________________

Date of last Medical Exam:

_________________

How would you describe your health?

Excellent

Very Good

Good

Fair

Others: Please describe?

_________________________________________________________________________________________

_____________________

____________________

Do you have a Medical Physician?

Yes: Name of Physician

Tel. #

______________

Are you now or have you been under the care of a physician within the past five years?

Yes If so, why?

______________________

_________

Have you had any major surgery or hospitalization?

Yes. Describe:

When:

___________________________________

Are you now or have you recently been taking any medication? If so, for what?

________

___________

Have you taken Phen-fen

Redux before?

Yes When?

Have you seen your physician after that?

Are you allergic to or have any reactions to any of the following:

Y N

Local Anesthetics (e.g. Novocain)

Aspirin

Iodine

Penicillin or any other antibiotics

Codeine

Latex rubber

Sulfa Drugs

Barbiturates

Others (please list)

Any metals(e.g. nickel, mercury)

Sedatives

Y N

WOMEN ONLY:

a) Are you pregnant or think you may be pregnant?

b.) Are you nursing?

c.) Are you practicing birth control medication?

DO YOU HAVE OR HAVE YOU HAD ANY OF THE FOLLOWING:

Y N

Heart Attack

Joint Replacement/Implant

Epilepsy or Seizures

Gonorrhea

Heart Failure

Kidney Trouble

Glaucoma

Cold Sores

Heart Surgery

Ulcers

Pain in Jaw Joints

Genital Herpes

Heart Disease

Arthritis

Aids or HIV Infection

Fainting/Dizzy Spells

Angina Pectoris

Emphysema

Liver Disease

Nervousness

Heart Murmur

Tuberculosis

Hepatitis A (infectious)

Psychiatric Treatment

High Blood Pressure

Asthma

Hepatitis B (serum)

Sickle Cell Disease

Rheumatic Fever

Hay Fever/Allergies

Hepatitis C

Bleeding Gums

Congenital Heart Defect

Sinus Trouble

Yellow Jaundice

Tooth Pain

Scarlet Fever

Diabetes

Blood Transfusion

Bad Breath

Artificial Heart Valve

Thyroid Disease

Drug Addiction

Chronic Headaches

Mitral Valve Prolapse

Radiation Therapy

Hemophilia

Chronic Neckaches

Heart Pace Maker

Chemotherapy

Syphilis

Cosmetic Surgery

Stroke

Cancer

Leukemia

Cortisone Medicine

Others not listed:

_______________________________________________________________________________________________________________________________

P A T I E N T D E N T A L H I S T O R Y

Y N

1. Do your gums bleed while brushing or flossing?

8. Do you have frequent headaches?

2. Are your teeth sensitive to hot or cold liquids/foods?

9. Do you clench or grind your teeth?

3. Are your teeth sensitive to sweet or sour liquids/foods?

10. Do you bite your lips or cheeks frequently?

4. Do you feel pain to any of your teeth?

11. Have you ever had any difficulty with extractions in the past?

5. Do you have any sores or lumps in or near your

12. Have you had any orthodontic treatment?

mouth?

6. Have you had any head, neck or jaw injuries?

13. Have you ever had any prolonged bleeding following extractions?

7. Have you ever experienced any of the following

14. Do you wear dentures or partials?

Problems in your jaw? a) Clicking

If yes, date of placement:

b) Pain (joint, ear, side of face)

15. Have you ever received oral hygiene instructions regarding

the care of your teeth and gums?

c) Difficulty in opening or closing

16. Do you like your smile?

d) Difficulty in chewing

A u t h o r i z a t i o n a n d R e l e a s e

I certify that I have read and understand the above information to the best of my knowledge. The above questions have been accurately

answered. I understand that providing incorrect information can be dangerous to my health. I authorize the dentist to release any information

including the diagnosis and the records of any treatment or examination rendered to me or my child during the period of such dental care to

third party payers and/or health practitioners.

__________________________________________________

______________

Signature of Patient/Parent or Guardian:

Date

________________________________________________________________

______________

Doctor’s Signature:

Date

Rev/Jarro-10/09

Patient Medical History Form

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