Wholeearthdentistry.com

MEDICAL HISTORY
Patient's name _______________________________________________ Phone ( ) Physician's name _____________________________________________ Phone ( ) Last seen approximately ____________________ Reason for visit ____________________________________ Are you under the care of a physician? □ Yes □ No If yes, for what condition(s)? _______________________ _________________________________________________________________________________________ Please list al medications you are currently taking ( Please include al prescription medication, over the counter medication, herbal remedies and vitamins)_______________________________________________________ _________________________________________________________________________________________ Please list any drug/medication al ergies _________________________________________________________ _________________________________________________________________________________________ Have you had any serious il ness in the last five years? □ Yes □ No If yes, please describe ________________________________________________________ Have you had any operations in the last five years? □ Yes □ No If yes, please describe ________________________________________________________ Have you ever responded adversely to medical or dental treatment? □ Yes □ No If yes, please describe _________________________________________________________ Have you experienced any major life changes or stressful events in the previous 12 months? □ Yes □ No Have you ever had any of the fol owing? (check al that apply) □ Developmental disorder (Type ____________________) Please list any other medical conditions or il nesses you may have that where not listed above: _____________ _________________________________________________________________________________________ _________________________________________________________________________________________ Do you use tobacco products? □ Yes □ No If yes, what type of product do you use? ____________________ How often do you use product?_____________________ How much do you use? _______________________ Have you had IV bisphosphonate (eg. Aredia or Zometa) therapy? □ Yes □ No
Have you ever taken oral bisphosphonate (eg. Actonel, Boniva, Fosamax, Skelif, or Didronel) therapy?
□ Yes □ No Women Only: Are you pregnant? □ Yes □ No □ Maybe Are you nursing? □ Yes □ No Are currently using birth control? □ Yes □ No Is there anything else in your medical history we should know about? __________________________________ _________________________________________________________________________________________ Dental History
Reason for today's visit: ______________________________________________________________________ Date of last dental care ________________________ Date of last dental x-ray _________________________ Month Year Month Year Have you experienced any of these problems? (check al that apply) □ Sores or growths in your mouth □ Gag easily List any dental problems you have experienced that are not listed: ____________________________________ _________________________________________________________________________________________ How often do you floss? _______________________ How often do you brush? _________________________Have you ever felt anxious about receiving dental treatment? □ Yes □ No Please let us know if you have any special areas of concern: ______________ Signature of patient (or parent, if minor)
Patient number

Source: http://www.wholeearthdentistry.com/docs/Medical_Dental_History.pdf