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PATIENT’S MEDICAL HISTORYPATIENT’S NAME __________________________________________________ DATE OF BIRTH _______________________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 THAT YOU WILL BE RECEIVING. THANK YOU FOR ANSWERING THE FOLLOWING 1. ARE YOU IN GOOD HEALTH . . . . . . . . . . . . . . . .
12. HAVE YOU EVER TAKEN FEN-PHEN/REDUX . . . . .
GENERAL HEALTH WITHIN THE PAST YEAR . . . . .
3. DATE OF YOUR LAST PHYSICAL EXAM: _________________ CONTAINING BISPHOSPHONATES . . . . . . . . . . .
4. PHYSICIAN’S NAME ________________________________ 14. HAVE YOU TAKEN VIAGRA, REVATIO, CIALIS OR ADDRESS _________________________________________ LEVITRA IN THE LAST 24 HOURS . . . . . . . . . . . .
PHONE NO. _______________________________________ 15. DO YOU USE TOBACCO . . . . . . . . . . . . . . . . . . .
PHYSICIAN . . . . . . . . . . . . . . . . . . . . . . . . . . . .
SUBSTANCES . . . . . . . . . . . . . . . . . . . . . . . . . . .
6. HAVE YOU EVER BEEN HOSPITALIZED FOR ANY 17. ARE YOU WEARING CONTACT LENSES . . . . . . . .
SURGICAL OPERATION OR SERIOUS ILLNESS . .
18. DO YOU HAVE A PERSISTENT COUGH OR THROAT PLEASE EXPLAIN. ____________________________________ ___________________________________________________ ILLNESS (LASTING MORE THAN 3 WEEKS) . . . . .
INCLUDING NON-PRESCRIPTION MEDICINE . . .
19. DO YOU HAVE ANY DISEASE, CONDITION OR IF YES, WHAT MEDICINE(S) ARE YOU TAKING ______________ ___________________________________________________ I SHOULD KNOW ABOUT . . . . . . . . . . . . . . . . . .
8. HAVE YOU HAD ANY ABNORMAL BLEEDING . . .
9. DO YOU BRUISE EASILY . . . . . . . . . . . . . . . . . . .
ARE YOU PREGNANT OR THINK YOU MAY BE PREGNANT . .
10. HAVE YOU EVER REQUIRED A BLOOD TRANSFUSION ARE YOU NURSING . . . . . . . . . . . . . . . . . . . . . . . . .
11. HAVE YOU HAD A RECENT WEIGHT LOSS . . . . . .
ARE YOU TAKING BIRTH CONTROL PILLS . . . . . . . . . . . .
HIVES OR SKIN RASH . . . . . . . . . . . . . . . . . . . . . . .
FAINTING OR DIZZY SPELLS . . . . . . . . . . . . . . . . .
LOCAL ANESTHETICS LIKE NOVOCAINE . . . . . . . . .
DIABETES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
PENICILLIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
AIDS OR HIV INFECTION . . . . . . . . . . . . . . . . . . . .
OTHER ANTIBIOTICS . . . . . . . . . . . . . . . . . . . . . . . . THYROID PROBLEMS . . . . . . . . . . . . . . . . . . . . . . .
SULFA DRUGS . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
ALLERGIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
BARBITURATES, SEDATIVES OR SLEEPING PILLS . . .
ARTHRITIS OR RHEUMATISM . . . . . . . . . . . . . . . . .
ASPIRIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
JOINT REPLACEMENT OR IMPLANT . . . . . . . . . . . .
IODINE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
STOMACH ULCER . . . . . . . . . . . . . . . . . . . . . . . . .
ANY METALS (E.G., NICKEL, MERCURY, ETC.) . . . . .
KIDNEY TROUBLE . . . . . . . . . . . . . . . . . . . . . . . . . .
LATEX / RUBBER . . . . . . . . . . . . . . . . . . . . . . . . . . . .
TUBERCULOSIS . . . . . . . . . . . . . . . . . . . . . . . . . . .
OTHER (PLEASE LIST) _________________________________ PERSISTENT COUGH . . . . . . . . . . . . . . . . . . . . . . .
COUGH THAT PRODUCES BLOOD . . . . . . . . . . . . .
CHEMOTHERAPY (CANCER, LEUKEMIA) . . . . . . . .
RHEUMATIC HEART DISEASE OR RHEUMATIC FEVER SEXUALLY TRANSMITTED DISEASE . . . . . . . . . . . . .
SCARLET FEVER . . . . . . . . . . . . . . . . . . . . . . . . . . . .
EPILEPSY OR SEIZURES . . . . . . . . . . . . . . . . . . . . .
HEART DEFECT OR HEART MURMUR . . . . . . . . . . . .
ANEMIA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
HEART TROUBLE, HEART ATTACK, OR ANGINA . . . .
GLAUCOMA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
CHEST PAIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
SHORTNESS OF BREATH . . . . . . . . . . . . . . . . . . . . .
NERVOUSNESS . . . . . . . . . . . . . . . . . . . . . . . . . . .
PACEMAKER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
TONSILLITIS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
HEART SURGERY . . . . . . . . . . . . . . . . . . . . . . . . . . .
TUMORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
HIGH/LOW BLOOD PRESSURE . . . . . . . . . . . . . . . .
MENTAL HEALTH CARE . . . . . . . . . . . . . . . . . . . . . .
CONGENITAL HEART PROBLEM . . . . . . . . . . . . . . . .
BACK PROBLEMS . . . . . . . . . . . . . . . . . . . . . . . . . .
SWELLING OF FEET, ANKLES, HANDS . . . . . . . . . . .
CHEMICAL DEPENDENCY . . . . . . . . . . . . . . . . . . .
HEPATITIS, JAUNDICE OR LIVER DISEASE . . . . . . . .
MITRAL VALVE PROLAPSE . . . . . . . . . . . . . . . . . . . .
STROKE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
CORTISONE TREATMENT . . . . . . . . . . . . . . . . . . . .
SINUS TROUBLE . . . . . . . . . . . . . . . . . . . . . . . . . . .
COLD SORES/FEVER BLISTERS . . . . . . . . . . . . . . . .
LUNG OR BREATHING PROBLEMS . . . . . . . . . . . . .
HYPOGLYCEMIA . . . . . . . . . . . . . . . . . . . . . . . . . .
ASTHMA OR HAY FEVER. . . . . . . . . . . . . . . . . . . . . . EATING DISORDERS . . . . . . . . . . . . . . . . . . . . . . . .
PATIENT’S NAME __________________________________________________ DATE OF BIRTH _______________________ REASON FOR THIS VISIT _______________________________________________________________________________________ WHEN WAS YOUR LAST DENTAL VISIT ____________________________ WHAT WAS DONE THEN ____________________________ HOW OFTEN DID YOU VISIT THE DENTIST BEFORE THEN _____________________________________________________________ PREVIOUS DENTIST (NAME AND LOCATION) _______________________________________________________________________ HAVE YOU HAD A COMPLETE SERIES OF DENTAL FILMS (X-RAYS) TAKEN WHEN/WHERE ___________________________________ HOW OFTEN DO YOU BRUSH YOUR TEETH ____________________ HOW OFTEN DO YOU FLOSS YOUR TEETH _________________ IS YOUR DRINKING WATER FLUORIDATED _________________________________________________________________________ DO YOU BITE YOUR LIPS OR CHEEKS FREQUENTLY OR FLOSSING . . . . . . . . . . . . . . . . . . . . . . . . . . .
YOUR TEETH . . . . . . . . . . . . . . . . . . . . . . . . . . . .
LIQUIDS/FOODS . . . . . . . . . . . . . . . . . . . . . . . . .
ARE YOUR TEETH SENSITIVE TO SWEET OR SOUR BETWEEN YOUR TEETH . . . . . . . . . . . . . . . . . . . .
LIQUIDS/FOODS . . . . . . . . . . . . . . . . . . . . . . . . .
DO YOU FEEL PAIN TO ANY OF YOUR TEETH . . . . .
TREATMENT (GUMS) . . . . . . . . . . . . . . . . . . . . . .
EVER WORN A BITE PLATE OR OTHER APPLIANCE . .
NEAR YOUR MOUTH . . . . . . . . . . . . . . . . . . . . . .
HAVE YOU EVER HAD ANY DIFFICULT EXTRACTIONS HAVE YOU HAD ANY HEAD, NECK OR JAW INJURIES IN THE PAST . . . . . . . . . . . . . . . . . . . . . . . . . . . .
FOLLOWING EXTRACTIONS . . . . . . . . . . . . . . . . .
CLICKING . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
DO YOU WEAR DENTURES OR PARTIALS . . . . . . . .
PAIN (JOINT, EAR, SIDE OF FACE) . . . . . . . . . . . .
IF YES, DATE OF PLACEMENT _________________________ DIFFICULTY IN OPENING OR CLOSING . . . . . . . .
DIFFICULTY IN CHEWING . . . . . . . . . . . . . . . . . .
DO YOU HAVE FREQUENT HEADACHES . . . . . . . . .
YOUR TEETH AND GUMS . . . . . . . . . . . . . . . . . . .
DO YOU CLENCH OR GRIND YOUR TEETH . . . . . . .
IF YOU COULD CHANGE ANYTHING ABOUT YOUR SMILE, WHAT WOULD YOU CHANGE? _____________________________________ ______________________________________________________________________________________________________________ ______________________________________________________________________________________________________________ AUTHORIZATION AND RELEASEI CERTIFY THAT I HAVE READ AND UNDERSTAND THE ABOVE INFORMATION TO INSURANCE COMPANY TO PAY DIRECTLY TO THE DENTIST OR DENTAL GROUP THE BEST OF MY KNOWLEDGE. THE ABOVE QUESTIONS HAVE BEEN INSURANCE BENEFITS OTHERWISE PAYABLE TO ME. I UNDERSTAND THAT MY ACCURATELY ANSWERED. I UNDERSTAND THAT PROVIDING INCORRECT DENTAL INSURANCE CARRIER MAY PAY LESS THAN THE ACTUAL BILL FOR INFORMATION CAN BE DANGEROUS TO MY HEALTH. I AUTHORIZE THE SERVICES. I AGREE TO BE RESPONSIBLE FOR PAYMENT OF ALL SERVICES DENTIST TO RELEASE ANY INFORMATION INCLUDING THE DIAGNOSIS AND RENDERED ON MY BEHALF OR MY DEPENDENTS.
THE RECORDS OF ANY TREATMENT OR EXAMINATION RENDERED TO ME OR MY CHILD DURING THE PERIOD OF SUCH DENTAL CARE TO THIRD PARTY ________________________________________________ DATE ________________ PAYORS AND/OR HEALTH PRACTITIONERS. I AUTHORIZE AND REQUEST MY SIGNATURE OF PATIENT OR PARENT/GUARDIAN IF MINOR DOCTOR’S COMMENTS __________________________________________________________________________________________ ______________________________________________________________________________________________________________ _____________________________ SIGNATURE _____________________________________________ DATE ____________________ Form 219114 N/04/11 Item 40684 Brad Pitts, D.M.D. Patterson Office Supplies 800.637.1140

Source: http://bradpitts.com/files/2013/02/health-hx.pdf