Dental Patient Medical History

Please correct the errors described below.

Patient's Name

Social Security #

Date of Birth

Home Phone No.

Work Phone No.

Cell Phone No.

Address

City

State

Zip

Email Address

Employer Name

Address

City

State

Zip

Marital Status

Single Married Widowed Divorced

The answers to the following questions will assist the dentist in evaluating your general health prior to providing your dental treatment.

PLEASE READ CAREFULLY AND ANSWER EACH QUESTION AS ACCURATELY AS POSSIBLE.

1. WHAT IS YOUR IMPRESSION OF YOUR PRESENT HEALTH?

2. YEAR LAST MEDICAL PHYSICAL?

3. Please check any of the following which you have had or have at present.

Heart Disease

Angina Pectoris

Frequent Chest Pains

High Blood Pressure

Shortness of Breath

Swollen Ankles

Artificial Heart Valve

Congenital Heart Disease

Heart Murmur

Rheumatic Fever

Stroke

Hemophilia

Bruise Easily

Prolonged or Unusual Bleeding

Anemia

Blood Transfusion

Sickle Cell Disease

Arthritis

Asthma

Hay Fever

Emphysema

Tuberculosis (TB)

Diabetes

Ulcers

Kidney Trouble

Liver Disease

Jaundice (Other than at birth)

Hepatitis

Thyroid Disease

Glaucoma

Epilepsy or Seizures

Fainting or Dizzy Spells

AIDS or AIDS Related Complex

HIV Positive

Cold Sores

Genital Herpes

Venereal Disease (Syphilis, Gonorrhea)

Drug Addiction

Psychiatric Treatment

Cancer

Radiation Therapy

Chemotherapy

Implant Prosthesis

Unexplained Weight Loss

4. ARE YOU PRESENTLY, OR HAVE YOU BEEN UNDER THE CARE OF A PHYSICIAN DURING THE PAST YEAR?

5. ARE YOU PRESENTLY TAKING ANY MEDICINE OR DRUGS?

If yes, Please Specify

6. ARE YOU ALLERGIC TO ANY MEDICINE OR MATERIALS?

If yes, Please Specify

7. HAVE YOU EVER HAD A REACTION TO A LOCAL ANESTHETIC?

8. HAVE YOU EVER EXPERIENCED ANY COMPLICATION OR ILLNESS FOLLOWING DENTAL TREATMENT?

9. DO YOU HAVE ANY DISEASES OR CONDITIONS NOT LISTED ABOVE?

If yes, Please Specify

10. HAVE YOU EVER BEEN TOLD YOU WERE NOT ELIGIBLE TO BE A BLOOD DONOR?

11. DO YOU USE TOBACCO? (If YES, please check and give frequency below)

Cigarettes

Cigars

Pipe

Smokeless: Chewing Tobacco Snuff or "Dip"

Frequency

12. HAVE YOU PARTAKEN IN ANY ILLEGAL SUBSTANCES IN THE PAST 24 HOURS?

13. WOMAN: ARE YOU PREGNANT?

If yes, Please choose trimester block

14. WHOM MAY WE THANK FOR REFERRING YOU TO OUR OFFICE?

Patient Comments

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Patient's Signature

Date

Your information will be encrypted.

Monem Dental Melbourne

(321) 242-2236
www.monemdentalmelbourne.com

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