Www.dovedental.com
PATIENT MEDICAL HISTORY_________________________________________________ ___/____/____ Patient Name Date of BirthWhen was your last dental visit:______________________________________________Do you have or have had any of the following? Please circle all that apply: Bleeding gums Grinding or clenching of teeth Painful or locking jawBroken fillings Injury to teeth or jaw Sensitivity to sweet, hot,Chronic bad breath Loose teeth cold, bitingDecayed teeth Orthodontic treatment Sores, growths or swelling Food catches between teeth Periodontal treatment in mouthMedical HistoryDo you have or have you had any of the following? Please circle all that apply:Anemia Chronic Cough Heart AttackArthritis, rheumatism Diabetes VertigoArtificial heart valves Epilepsy/Seizures Nervous disorderArtificial joints Fainting Dental anxiety Asthma Kidney disease PacemakerSinus problems Headaches/migraine Shortness of breathAutoimmune disease Circulatory problems Low blood pressure Lung disorder Blood disease Chemotherapy Stroke Abnormal bleeding Cancer Liver disease Heart disease Hepatitis Congestive heart failure Radiation treatment High blood pressureProlonged healing HIV positive Thyroid diseaseBruising easily Venereal disease Are you allergic to any of the following drugs? Please circle: PenicillinAspirin Erythromycin TetracyclineCodeineLatexOther________________________________________________________________________ Allergies:_____________________________________________________________________ Please list all medications you are currently taking: _________________________________________________________________________________________________________________(PLEASE SEE OTHER SIDE)Are you presently under a physician’s care?_______________Reason:_______________________________________________________________________Do you require Premedication before dental appointments?____________________________Are you allergic to any dental anesthetics?__________________________________________Use of tobacco?________________________________________________________________(Women) Are you pregnant?______________ Nursing_________________ ................
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