Smiles of America - Medical History of Patient

Medical History of Patient

CONFIDENTIAL	Chart No
Please print and complete fully	Phone:
Patient Name Date of birth Sex M F
Why are you here today? Toothache Estimate Check-Up
It is important that we know about your medical history. Many things have a direct bearing on your dental health. We will review the questionnaire and discuss it with you in detail. Information you give us is strictly confidential and will not be released to anyone without your written permission.
Medical Physician’s Name Date of last examination
In case of emergency, notify Phone #
Nearest relative Phone #
Address City State Zip Code

Please indicate with a check mark (√) if you are allergic to any of the following
Yes No		Yes No		Yes No		Yes No
	Local Anesthetics		Sulfa Drugs		Codeine		Other Narcotics
	Penicillin		Other Antibiotics		Aspirin		Latex Sensitivity
	Barbiturates Seda.		Food		Odine		Other

Women, Please indicate with a check mark (√) any of the following
Yes No		Yes No		Yes No		Yes No
	Pregnant		Pregnancy Planning		Nursing		Use of Contraceptives

Do you currently have, or have you had any of the following? Please indicate with a check mark (√)
Yes No		Yes No		Yes No		Yes No
	Heart Problems		MS/MD/Cerebral Palsy		Scarlet Fever		Positive HIV
	Heart Murmur		Epilepsy		Tonsillitis		AIDS
	High Blood Pressure		Hemophilia		Tuberculosis		Blood Transfusion
	Low Blood Pressure		Arthritis		Artificial Joints		Dates
	Circulatory Problems		Asthma		Malignancies		Sinus Problems
	Stroke		Allergies to Anesthetics		Typhoid Fever		Diabetes
	Pacemaker		Measles		Mumps		Psychiatric Care
	Bleeding Problems		Rheumatic fever		Ulcer		Are you pregnant?
	Anemia		Hepatitis: A B C		STD		Tobacco use
	Nervous System/Problem		Allergy to latex		Use of phen-phen		Other
	Allergies to Medications (list)
	Home Remedies/Herbs (list)

Explain of any above:
List all medications you are currently taking (or within past 30 days)(Prescribed or over-the-counter, i.e. antibiotic, birth control, aspirin, etc)
Are you currently under the care of a physician? Yes No, explain:
Have you been hospitalized for any reason in the past 5 years? Yes No, explain:
Are you extremely nervous about dental visits?
When was the last time you were with the dentist?
Why did you leave your last dentist?
Have you had any problems with your previous dental treatment?
When was the last time you had a cleaning?
How do you like your smile?
Whom may we thank for referring you?
Signature (parent signature if under 18):
Authorization and Release I certify that I have read and understand the above informationto the best of my knowledge. The above question have been accurately answered. I understand that providing incorrect information can be dangerous to my health . I authorized the dentist to release any information including the diagnosis and the records of any treatment or examination rendered to me or my child during the period of such Dental care to third party payor and / or health practitioners
Signature of patient or parent if minor Date

Dentist Notes
Date	Comments	Patient	Dentist	Witness