Microsoft word - health form.doc

MEDICAL HISTORY
PATIENT NAME________________________________________ DOB_______________ DATE________________________ Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions. Are you under a physician’s care now? O Yes O No If yes, explain________________________________ Have you ever been hospitalized or had a major operation? O Yes O No If yes, explain________________________________ Have you ever had a serious head or neck injury? O Yes O No If yes, explain________________________________ Are you taking any medications, pills, or drugs? O Yes O No If yes, explain________________________________ If yes, explain________________________________ If yes, explain________________________________ Have you taken Bisphosphonate drugs (such as Fosamax)? O Yes O No If yes, IV or Oral, explain_______________________ Do you use controlled substances? O Yes O No Women Are you:
O Pregnant/Trying to get pregnant? O Nursing? O Taking oral contraceptives? Are you allergic to any of the following?
O Aspirin O Penicillin O Codeine O Local Anesthetics O Acrylic O Metal O Latex O Other ____________________ Do you have or have you had any of the following?
AIDS/HIV Positive O Yes O No Diabetes O Yes O No Herpes O Yes O No Rheumatism O Yes O No
Alzheimer’s Disease O Yes O No Do you smoke O Yes O No High Blood Pressure O Yes O No Scarlet Fever O Yes O No Anaphylaxis O Yes O No Drug Addiction O Yes O No Hives or Rash O Yes O No Shingles O Yes O No O Yes O No Easily Winded O Yes O No Hypoglycemia O Yes O No Sickle Cell Disease O Yes O No Emphysema O Yes O No Irregular Heartbeat O Yes O No Sinus Trouble O Yes O No Anorexia/Bulimia O Yes O No Epilepsy or Seizures O Yes O No Kidney Problems O Yes O No Spina Bifida O Yes O No Arthritis O Yes O No Excessive Bleeding O Yes O No Leukemia O Yes O No Stomach/ Artificial Heart Valve O Yes O No Excessive Thirst O Yes O No Liver Disease O Yes O No Intestinal Disease O Yes O No Artificial Joint O Yes O No Fainting Spells/Dizziness O Yes O No Low Blood Pressure O Yes O No Stroke O Yes O No Asthma O Yes O No Frequent Cough O Yes O No Lung Disease O Yes O No Blood Disease O Yes O No Frequent Diarrhea O Yes O No Lupus O Yes O No Thyroid Disease O Yes O No Blood Transfusion O Yes O No Frequent Headaches O Yes O No Multiple Sclerosis O Yes O No Tonsillitis O Yes O No Breathing Problem O Yes O No Genital Herpes O Yes O No Mitral Valve Prolapse O Yes O No Tuberculosis O Yes O No Bruise Easily O Yes O No Glaucoma O Yes O No Pacemaker O Yes O No Tumors or Growths O Yes O No Cancer O Yes O No Hay Fever O Yes O No Pain in Jaw Joints O Yes O No Ulcers O Yes O No Chemotherapy O Yes O No Heart Attack/Failure O Yes O No Parathyroid Disease O Yes O No Venereal Disease O Yes O No Chest Pains O Yes O No Heart Murmur O Yes O No Parkinsons O Yes O No Yellow Jaundice O Yes O No Cold Sores/Fever Blisters O Yes O No Heart Pace Maker O Yes O No Psychiatric Care O Yes O No Heart Trouble/Disease O Yes O No Radiation Treatment O Yes O No Any other illness? O Yes O No Disorder O Yes O No Hemophilia O Yes O No Recent Weight Loss O Yes O No Explain:____________________ Convulsions O Yes O No Hepatitis A O Yes O No Renal Dialysis O Yes O No ___________________________ Cortisone Medicine O Yes O No Hepatitis B or C O Yes O No Rheumatic Fever O Yes O No DENTAL HISTORY
Have you received any recent dental treatment? If yes, what, when, & where? _____________________________ Do you have anxiety about your dental visit? If yes, please explain? ___________________________________ If no, what don’t you like? ________________________________ If yes, please explain? ___________________________________ What is your MAIN DENTAL CONCERN:_____________________________________________________________________
Comments:_______________________________________________________________________________________________ _______________________________________________________________________________________________ To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient’s) health. It is my responsibility to inform the dental office of any changes in medical status as they occur. ________________________________________________________________________ ___________________________________________ SIGNATURE OF PATIENT, PARENT, or GUARDIAN Warden Eglinton Dental Centre 1921 Eglinton Ave E, Unit 8E, Scarborough, ON M1L 2L6 416-751-4290 reception@wedental.ca

Source: http://wedental.ca/Team_files/Health%20Form.pdf