Medical History Evaluation

Medical History Evaluation

Medical History Form Sample

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Our Dental Office Medical History Form

Your Name Phone Numbers Address City, State, Zip

Primary Care Provider’s Name & Office Phone Numbers Address City, State, Zip

Please check Yes or No to the following questions. (Your responses are confidential).

Current Health Status

Yes No

Do you consider yourself to be presently in good health? If not, why?

Have there been changes to your health during the past year? If so, please describe.

Do you now have or have you had an illness that required care by a physician or surgeon, within the last 5 years? If so, what illness?

Have you been hospitalized for an illness or surgical operation? If so, please describe.

The following medical history questions are listed according to corresponding body systems. If you respond positively to any question, please circle the condition that applies. Feel free to provide additional information on the back of each page.

A. Central Nervous System Yes No

Do you have epilepsy, seizures, or fainting spells? Do you have multiple sclerosis, cerebral palsy, or Parkinson’s disease?

B. Musculo-Skeletal System Yes No

Do you have arthritis, rheumatism, or swollen joints? Do you have prosthetic replacements? Example: hip, joint

C. Gastrointestinal System Yes No

Do you have stomach ulcers or frequent heartburn? Do you have or have you had hepatitis, jaundice, or liver disease? Have you had a liver transplant?

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D. Genito-Urinary System Yes No

Do you have or have you had kidney disease? Are you missing one or both kidneys? Are you on dialysis? Have you had a kidney transplant? Have you had gonorrhea, syphilis, herpes, other?

Females Yes No

Are you pregnant? If so, are you experiencing complications? Describe them:

Have you had a miscarriage or stillbirth? Have you had a baby with low birth weight or birth weight of more than 10 pounds?

Are you presently nursing? Are you taking oral contraceptives? Do you have problems associated with your menstrual cycle? Are you menopausal? Do you have osteoporosis or thinning of your bones? Have you had fractures of any bones? Do you have osteonecrosis of the jaw?

Males Yes No

Do you have a penile implant?

E. Endocrine System Yes No Do you or have you had to urinate more than 6 times per day? Do you or have you had thirst much of the time? Do you or have you had dry mouth much of the time? Do you or have you had rapid weight loss? Do you have thyroid disease?

F. Respiratory System Yes No

Do you or have you had tuberculosis? Do you have chronic obstructive lung disease or emphysema? Do you have or had you had persistent cough, night sweats, coughing up of blood, difficulty breathing, or chest pain?

Do you have asthma or hay fever? Do you have thyroid disease?

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G. Cardiovascular System Yes No

Do you have or have you had rheumatic fever or rheumatic heart disease? Have you had a heart attack, heart failure, angina pectoris, or a stroke? Do you have a heart murmur, or have you been told in the past that you had one?

Do you have congenital heart disease? Have you had infective (bacterial) endocarditis? Do you have mitral valve prolapse? If so, is there valvular dysfunction?

Do you have an implanted pacemaker or a defibrillator? Do you have a prosthetic heart valve? Do you have any other type of synthetic replacement in the cardiovascular system?

Have you had open heart surgery? If so when and what type.

Do you have hypertension (high blood pressure)? Do you have or have you had: Shortness of breath after exercise? Shortness of breath when lying down? To sleep with extra pillows? Chest pain upon exertion? Ankle swelling? Palpitations (heart beasts fast)?

Do you have any other type of cardiovascular health conditions? If so, please describe:

H. Hematologic System Yes No Do you have any form of anemia? Do you have leukemia? Do you have hemophilia or other bleeding problems? Do you have or have you had a problem with excessive bleeding? Do you have relatives who have bleeding problems? Have you had spontaneous bleeding from the nose, mouth, or ears? Have you ever had a blood transfusion? If so when and why:

Have you had pallor (white look)?

I. Immune System and Neoplasia Yes No Do you have allergies? Do you have or have you had a skin rash or hives? Do you have HIV? Do you have AIDS? Do you have sores in your mouth? Do you have white lesions in your mouth? H Have you had night sweats? Have you had any unusual weight loss? Do you have any lumps or tumors in your mouth or on your neck? Have you been or are you being treated for cancer with surgery, radiation or chemotherapy?

Do you use tobacco? If so, what kind, how often and for how long have you used it?

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J. Sensory System Yes No

Do you have an eye disorder such as glaucoma, macular degeneration, cataracts, or blindness?

Do you wear a hearing aid or are you hard of hearing?

K. Behavioral System Yes No Are you depressed or being treated for depression? Do you have an anxiety disorder or phobia related to dental care? Do you have dementia or Alzheimer's Disease? Do you have a psychiatric condition such as schizophrenia? Are you chemically dependent? Do you use cocaine recreationally? Do you have an eating disorder such as anorexia or bulimia?

L. Medications and Drugs Yes No

Are you presently taking medications or drugs? If so, circle the specific type of drug listed below and provide the name of the medication: Antibiotics? Anticoagulants (blood thinners)? Antihistamines? Antihypertensive (blood pressure medication)? Aspirin or other pain medication? Cortisone or steroids? Digitalis or medications for the heart? Dilantin or medication to control seizures? Insulin, Micronase, or other medication to control diabetes? Medicine for depression or other psychiatric disorder? Nitroglycerin? Tranquilizers or sedatives? Hallucinogens (e.g., LSD, cocaine, methamphetamine) Any other medications or drugs (including over-the-counter drugs and herbal medicines?

Are you allergic to or have you ever reacted adversely to the following? If so, circle the specific type of drug listed below and provide the name of the medication or drug: Aspirin? Barbiturates, sedatives, or sleeping pills? Local anesthetics such as Novocain? Penicillin or other antibiotics? Sulfa drugs? Any other medications or drugs?

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