Medical history

MEDICAL HISTORY
NAME: ______________________ Date:________________
Date of Birth________________________ Occupation:______________
1. Have you been under the care of a medical doctor during the past three years? Yes No
If yes, for what?______________________________________________________________
Physician’s Name:___________________________ Phone Number:___________________
Address_________________________________ City_______________State_____Zip_________
2. Have you taken any medications or drugs during the past two years? Yes No
3. Are you taking any medication, drugs or pill now, including regular dosages of aspirin? Yes
No
If yes, please list name and dosage_____________________________________________________
__________________________________________________________________________________
4. Have you ever taken prescription medications for weight loss (diet pills)? Yes No
If yes, did you take any of the following: Fen-Phen (Fenfluramine-Phentermine) Yes No
Pondimen (Fenfluramine) Yes No
Redux (Dexfenfluramine) Yes No
If yes to any of the above, did you have a medical exam for heart tissue? Yes No
5. Are you or have you taken any of the following medications?
_____ Residronate (Actonel) _____ Tiludronate (Skelid) _____ Pamidronate (Aredia)
_____ Etidronate (Didronel) _____ Alendronate (Fosamax) _____ Zolendronate (Zometa)
How long were you taking medication? ___________ How taken?______ Oral _______IV
6. Are you aware of having an allergic (or adverse) reaction to any medication or substance? Y N
If yes, please list:___________________________________________________________________

7. Have you been a patient in the hospital during the past five years? Yes No
If “Yes”, for what:__________________________________________________________
8. Do you use more than two pillows to sleep? Yes No
9. Have you lost or gained more than 10 pounds in the past year? Yes No
10. Do you have to Pre-Medicate prior to having any dental cleanings or work done? Yes No
11. WOMEN: Are you: Pregnant? Yes, ______Months No
Nursing? Yes No
Taking Birth Control pills? Yes No


NAME: _______________________ page 2
Indicate which of the following you have had, or have at present. Circle “yes” or “no”

Chest Pain Yes No Hay Fever Yes No
Congenital Heart Disease Yes No Asthma Yes No
Heart (surgery,disease,attack) Yes No When:______ Tuberculosis Yes No
Heart Murmur Yes No Chronic Cough Yes No
Artificial Heart Valve Yes No Contact Lenses Yes No
Heart Pacemaker Yes No Drug/Alcohol Addiction: Yes No
Mitral Valve Prolapse Yes No High Blood Pressure Yes No
Allergies or Hives Yes No A.I.D.S. Yes No
Latex Sensitivity Yes No H.I.V. Positive Yes No
Rheumatic Fever Yes No Cold Sores/Fever Blisters Yes No
Arthritis/Rheumatism Yes No Blood Transfusion Yes No
Cortisone Medicine Yes No Hemophilia Yes No
Swollen Ankles Yes No Sickle Cell Disease Yes No
Stroke Yes No Bruise Easily Yes No
Diet (Special/Restricted) Yes No Liver Disease Yes No
Artificial Joints (hip, Knee, Etc) Yes No Yellow Jaundice Yes No
Kidney Trouble Yes No Neurological Disorders Yes No
Ulcers Yes No Epilepsy or Seizures Yes No
Diabetes Yes No Fainting or Dizzy Spells Yes No
Thyroid Problems Yes No Nervous/ Anxious Yes No
Glaucoma Yes No Psychiatric/Psychological Care Yes No
Emphysema Yes No Tumors Yes No
Sinus Trouble Yes No Venereal Disease/HPV/Herpes Yes No
Hepatitis “A” Yes No Cancer Yes No Type:____________
Hepatitis “B” Yes No Radiation Yes No When:____________
Headaches Yes No Chemotherapy Yes No When:________
Back Problems Yes No
Do you have or have you had any disease, condition, or problem not listed? Yes No
If yes, please List:_______________________________________________________________
I understand the above information is necessary to provide me with dental care in a safe and efficient
manner. I have answered all questions to the best of my knowledge. Should further information be
needed, you have my permission to ask the respective health care provider or agency, who may release
such information to you. I will notify the Doctor of change in my health or medication.
Patient/Guardian Signature:____________________________________________Date:______________

MEDICAL HISTORY UPDATE
DATE PATIENT SIGNATURE COMMENTS

______________________________________________________________________________________

Source: http://www.smalldental.com/patient-info/medical_history.pdf