Patient Medical History Update

Barnes Dental

Dental History

Are you currently experiencing any dental pain or discomfort?

Yes No

If yes, please explain

Has a physician or previous dentist recommended that you take antibiotics before having dental work?

Yes No

If yes, please explain

Are you taking any blood thinners (such as Coumadin, Warfarin, Xarelto, Pradaxa, Plavix, heparin or aspirin?

Yes No

If yes, please explain

Are you taking any medication to treat osteoporosis or Paget's disease?

Yes No

If yes, please explain

Are you taking hormonal replacement?

Yes No

If yes, please explain

Do you use any form of tobacco or nicotine products?

Yes No

If yes, please explain

Do you use vaping products?

Yes No

If yes, please explain

Do you use controlled substances (drugs), including marijuana, for either medicinal or recreational reasons?

Yes No

If yes, please explain

Do you take any other prescriptions and/or over-the-counter medicine(s), vitamins, herbs and/or supplements?

Yes No

If yes, please explain

If other, please specify

WOMEN ONLY: Are you:

Taking birth control pills?

Yes No

Pregnant: If yes number of weeks:

Yes No

If yes

Nursing: If yes number of weeks:

Yes No

If yes

Physician's name and phone number

Yes No

If yes

General Questions

Have you had a serious illness, operation or been hospitalized in the past 5 years

Yes No

Have you had any type (total or partial) joint replacement

Yes No

Have you had a heart valve replacement or heart surgery

Yes No

Have you had an organ or bone marrow/stem cell transplant

Yes No

Have you traveled internationally within the last 30 days

Yes No

Have you had a fever (100.4) in the last 72 hours

Yes No

If you have answered yes to any of these questions please explain

If yes

Do you have any disease, condition, or problem not listed here? If so, please explain

Yes No

If yes

Comments

Signature of Patient, Parent or Guardian

Date

Signature of Provider

Date

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