Medical History Patient Details

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Medical History Contact Information

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Medical History Do you have ANY of the following diseases or problems

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Check DK if you Don’t Know the answer to the question

  •  Yes
  •  No
  •  Dont Know
  •  Yes
  •  No
  •  Dont Know
  •  Yes
  •  No
  •  Dont Know
  •  Yes
  •  No
  •  Dont Know

Medical History Medical Information

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Please Select your response to indicate if you have or have not had any of the following diseases or problems.

  •  Yes
  •  No
  •  Dont know
  •  Yes
  •  No
  •  Dont know
  •  Yes
  •  No
  •  Dont know
  •  Yes
  •  No
  •  Dont know
  •  Yes
  •  No
  •  Dont Know

Oral Systemic Health is the connection between oral health and overall health. Our medical history is extensive in order to develop a full picture of your overall health. The other medical conditions throughout your body can affect the health of your mouth and vice versa.

Please Select  your response to indicate if you have or have not had any of the following diseases or problems. If you Select “YES”, please indicate whether it’s something you’ve had in the past or if it’s a current condition.

Lifestyle

  •  No
  •  Yes
  •  Current
  •  Past
  •  No
  •  Yes
  •  Current
  •  Past
  •  VERY
  •  SOMEWHAT
  •  NOT INTERESTED
  •  No
  •  Yes
  •  Current
  •  Past

Heart Conditions

  •  No
  •  Yes
  •  Current
  •  Past
  •  No
  •  Yes
  •  Current
  •  Past
  •  No
  •  Yes
  •  Current
  •  Past
  •  No
  •  Yes
  •  current
  •  Past
  •  No
  •  Yes
  •  Current
  •  Past
  •  No
  •  Yes
  •  Current
  •  Past
  •  No
  •  Yes
  •  Current
  •  Past
  •  No
  •  Yes
  •  Current
  •  Past
  •  No
  •  Yes
  •  Current
  •  Past
  •  No
  •  Yes
  •  Current
  •  Past
  •  No
  •  Yes
  •  Curent
  •  Past
  •  No
  •  Yes
  •  Current
  •  Past
  •  No
  •  Yes
  •  Current
  •  Past
  •  No
  •  Yes
  •  Current
  •  Past
  •  No
  •  Yes
  •  Current
  •  Past
  •  No
  •  Yes
  •  Current
  •  Past
  •  No
  •  Yes
  •  Current
  •  Past
  •  No
  •  Yes
  •  Current
  •  Past
  •  No
  •  Yes
  •  Current
  •  Past
  •  No
  •  Yes
  •  Current
  •  Past
  •  No
  •  Yes
  •  Current
  •  Past

Conditions Requiring Antibiotic Prophylaxis

  •  No
  •  Yes
  •  Current
  •  Past
  •  No
  •  Yes
  •  Current
  •  Past
  •  No
  •  Yes
  •  Current
  •  Past

Congenital heart diseases (CHD)

  •  No
  •  Yes
  •  Current
  •  Past
  •  No
  •  Yes
  •  Current
  •  Past
  •  No
  •  Yes
  •  Current
  •  Past
  •  No
  •  Yes
  •  Current
  •  Past

Bone Conditions

  •  No
  •  Yes
  •  Current
  •  Past
  •  No
  •  Yes
  •  Current
  •  Past
  •  No
  •  Yes
  •  Current
  •  Past
  •  No
  •  Yes
  •  Current
  •  Past

Neurological Conditions

  •  No
  •  Yes
  •  Current
  •  Past
  •  No
  •  Yes
  •  Current
  •  Past
  •  No
  •  Yes
  •  Current
  •  Past
  •  No
  •  Yes
  •  Current
  •  Past
  •  No
  •  Yes
  •  Current
  •  Past

Lung & Airway Conditions

  •  No
  •  Yes
  •  Current
  •  Past
  •  No
  •  Yes
  •  Current
  •  Past
  •  No
  •  Yes
  •  Current
  •  Past
  •  No
  •  Yes
  •  Current
  •  Past
  •  No
  •  Yes
  •  Current
  •  Past

Medical History

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Gastrointestinal (GI) Conditions

  •  No
  •  Yes
  •  Current
  •  Past
  •  No
  •  Yes
  •  Current
  •  Past
  •  No
  •  Yes
  •  Current
  •  Past
  •  No
  •  Yes
  •  Current
  •  Past
  •  No
  •  Yes
  •  Current
  •  Past
  •  No
  •  Yes
  •  Current
  •  Past
  •  No
  •  Yes
  •  Current
  •  Past
  •  No
  •  Yes
  •  Current
  •  Past

Autoimmune Conditions

  •  No
  •  Yes
  •  Current
  •  Past
  •  No
  •  Yes
  •  Current
  •  Past
  •  No
  •  Yes
  •  Current
  •  Past
  •  No
  •  Yes
  •  Current
  •  Past

Women Only

  •  No
  •  Yes
  •  Current
  •  Past
  •  No
  •  Yes
  •  Current
  •  Past
  •  No
  •  Yes
  •  Current
  •  Past

Blood Conditions

  •  No
  •  Yes
  •  Current
  •  Past
  •  No
  •  Yes
  •  Current
  •  Past
  •  No
  •  Yes
  •  Current
  •  Past
  •  No
  •  Yes
  •  Current
  •  Past
  •  No
  •  Yes
  •  Current
  •  Past

Medical History

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Endocrine System Conditions

  •  No
  •  Yes
  •  Current
  •  Past
  •  No
  •  Yes
  •  Current
  •  Past
  •  No
  •  Yes
  •  Current
  •  Past
  •  No
  •  Yes
  •  Current
  •  Past
  •  No
  •  Yes
  •  Current
  •  Past

Allergies

Are you allergic to or have you had a reaction to: To all yes responses, specify type of reaction.

  •  No
  •  Yes
  •  Current
  •  Past
  •  No
  •  Yes
  •  Current
  •  Past
  •  No
  •  Yes
  •  Current
  •  Past
  •  No
  •  Yes
  •  Current
  •  Past
  •  No
  •  Yes
  •  Current
  •  Past
  •  No
  •  Yes
  •  Current
  •  Past
  •  No
  •  Yes
  •  Current
  •  Past
  •  No
  •  Yes
  •  Current
  •  Past
  •  No
  •  Yes
  •  Current
  •  Past
  •  No
  •  Yes
  •  Current
  •  Past
  •  No
  •  Yes
  •  Current
  •  Past
  •  No
  •  Yes
  •  Current
  •  Past
  •  No
  •  Yes
  •  Current
  •  Past

Other Conditions

  •  No
  •  Yes
  •  Current
  •  Past
  •  No
  •  Yes
  •  Current
  •  Past
  •  No
  •  Yes
  •  current
  •  Past
  •  No
  •  Yes
  •  Current
  •  Past
  •  No
  •  Yes
  •  Current
  •  Past
  •  No
  •  Yes
  •  Current
  •  Past
  •  No
  •  Yes
  •  Current
  •  Past
  •  No
  •  Yes
  •  Current
  •  Past
  •  No
  •  Yes
  •  Current
  •  Past

NOTE: Both Doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment.

I certify that I have read and understand the above and that the information given on this form is accurate. I understand the importance of a truthful health history and that my dentist and his/her staff will rely on this information for treating me. I acknowledge that my questions, if any, about inquiries set forth above have been answered to my satisfaction. I will not hold my dentist, or any other member of his/her staff, responsible for any action they take or do not take because of errors or omissions that I may have made in the completion of this form.

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