Dental and Medical History

General Information

Name

Birth date

Age

Sex

Contact phone numbers

Reason for my dental appointment

(Optional) Take photo of dental concern

Are you in dental pain?

1 = Mild Pain
10 = Severe Pain
Where is the pain?

Describe the pain

Date of last examination

Were you satisfied with your last dental care?

Do you fear receiving dental care?

Any other dental concerns?

Information for your Dentist

Any allergies?

Please list any allergies:

Prescribed and over-the-counter medications/vitamins you are taking:

Any previous reactions to local anesthetic, metals, or sedation:

Any illnesses/surgeries/hospitalizations:

Any use of recreational drugs:

Medical History

Do you now or have you ever had:

Abnormal Blood Pressure

Alcohol Addiction

AIDS/HIV

Anemia

Anorexia

Artificial Heart Valve

Artificial Joint

Asthma/Breathing Issues

Bulimia

Cancer/Malignancy

Chemical Dependency

Chemotherapy

Congenital Heart Disease

Diabetes

Recreational Drugs

Emphysema

Emphysema

Epilepsy (seizures)

Fainting Spells

Hearing Problems

Heart Disease/Surgery

Heart Pacemaker

Hemophilia

Hepatitis

Hepatitis A

Hepatitis B

Hepatitis C

Kidney Problems

Learning Disability

Mitral Valve Prolapse

Neurological Disorders

Organ Transplant

Pregnant/Nursing

Prolonged Bleeding

Prosthetic Implants

Psychiatric Care

Radiation Therapy

Rheumatic Fever

Rheumatic Heart Disease

Sickle Cell Disease

Sinus Trouble

Stroke

Tuberculosis

Patient/Guardian Name and Signature:
Dentist Signature
Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.