Dental Medical History Form

• Dental Clinic/Hospital

• Conducted on

  Date

• Prepared by

• Location
  Address

General Information

• Name

• Birth date

  Date

• Age

• Sex

• Contact phone numbers

• Reason for my dental appointment

• (Optional) Take photo of dental concern

  Media

• Are you in dental pain?

  Yes

  No

• 1 = Mild Pain 10 = Severe Pain

• Where is the pain?

  Select Upper Right Upper Front Upper Left Lower Right Lower Front Lower Left

  • Upper Right
  • Upper Front
  • Upper Left
  • Lower Right
  • Lower Front
  • Lower Left

• Describe the pain

  Throbbing

  Sharp

  Consistent

  Intermittent

  Dull

• Date of last examination

  Date

• Were you satisfied with your last dental care?

  Not Satisfied

  Satisfied

  Very Satisfied

• Do you fear receiving dental care?

  Yes

  No

  Unsure

• Any other dental concerns?

Information for your Dentist

• Any allergies?

  Yes

  No

• 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

  Yes

  No

• Alcohol Addiction

  Yes

  No

• AIDS/HIV

  Yes

  No

• Anemia

  Yes

  No

• Anorexia

  Yes

  No

• Artificial Heart Valve

  Yes

  No

• Artificial Joint

  Yes

  No

• Asthma/Breathing Issues

  Yes

  No

• Bulimia

  Yes

  No

• Cancer/Malignancy

  Yes

  No

• Chemical Dependency

  Yes

  No

• Chemotherapy

  Yes

  No

• Congenital Heart Disease

  Yes

  No

• Diabetes

  Yes

  No

• Recreational Drugs

  Yes

  No

• Emphysema

  Yes

  No

• Emphysema

  Yes

  No

• Epilepsy (seizures)

  Yes

  No

• Fainting Spells

  Yes

  No

• Hearing Problems

  Yes

  No

• Heart Disease/Surgery

  Yes

  No

• Heart Pacemaker

  Yes

  No

• Hemophilia

  Yes

  No

• Hepatitis

  Yes

  No

• Hepatitis A

  ✔

  ✖

• Hepatitis B

  ✔

  ✖

• Hepatitis C

  ✔

  ✖

• Kidney Problems

  Yes

  No

• Learning Disability

  Yes

  No

• Mitral Valve Prolapse

  Yes

  No

• Neurological Disorders

  Yes

  No

• Organ Transplant

  Yes

  No

• Pregnant/Nursing

  Yes

  No

• Prolonged Bleeding

  Yes

  No

• Prosthetic Implants

  Yes

  No

• Psychiatric Care

  Yes

  No

• Radiation Therapy

  Yes

  No

• Rheumatic Fever

  Yes

  No

• Rheumatic Heart Disease

  Yes

  No

• Sickle Cell Disease

  Yes

  No

• Sinus Trouble

  Yes

  No

• Stroke

  Yes

  No

• Tuberculosis

  Yes

  No

• Patient/Guardian Name and Signature:

  Sign

• Dentist Signature

  Sign