Medical History Form

 

The information provided on this form is important to your dental health. Please complete all of questions to the best of your ability. If there have been any changes in your health, please tell us. Questions are welcome and appreciated.

 

The security of your information is very important to us. This form is fully secure and your information will be protected. To learn more about the security measures used on this form, click the security logo to the right.

Contact Information

Patient First Name: *

Patient Middle Name:

Patient Last Name: *

Patient Email: *

Home phone: *

Work phone:

Cell phone:

 

Preferred way to contact: *

Home phone Cell phone Email Work phone  

 

Date of birth: *

  

Patient Gender: *

  Male   Female  

Emergency Contact Name:

Emergency Contact Phone:

 
 
 

Health History

Primary Medical Doctor:

When was your last physical?

Date of last dental visit(if not here):

Clinic / Doctor:

Emergency Contact/Phone Number:

Preferred Pharmacy:

Do YOU (Not family members) have any of these conditions?

 

Diabetes

Yes No  

High blood pressure

Yes No  

MS, stroke, seizures

Yes No  

High levels of cholesterol

Yes No  

Asthma or breathing disorders

Yes No  

Allergy - Seasonal

Yes No  

Environmental

Yes No  

Sinus conditions

Yes No  

Weight loss / gain

Yes No  

Skin - Rosacea

Yes No  

Cancer

Yes No  

Headache

Yes No  

Communicable diseases

Yes No  

HIV

Yes No  

Chlamydia

Yes No  

Thyroid trouble

Yes No  

Rheumatoid arthritis

Yes No  

Shingles / herpes zoster

Yes No  

Sleep disorders

Yes No  

Ulcers or kidney disorders

Yes No  

 

Are you pregnant?

Yes No  

Do you have a history of cancer?

Yes No  

If so, what kind of cancer?

 

Please list any medications and supplements you are currently taking:

Please list any known medications you have had an allergic reaction to:

 

Have you been diagnosed with?

Gum disease

Gingivitis

Tooth infection

 

Do you have a family history of?

Heart disease

Cancer

Diabetes

 

Have you had?

A tooth or jaw injury

Periodontal treatments

Orthodontic treatment (braces, etc)

Root canal procedure

Oral surgery

 

Are you bothered by?

Tooth pain

Dry mouth

Uneven bite

Tooth color/appearance

Rough / sharp tooth surface

Bad breath

Social History

Do you live alone?

Yes No  

Do you smoke?

Yes No  

If so, number of packs/day:

Do you consume alcohol?

Yes No  

If so, number of drinks/day:

Occupation / Recreation

Occupation (if any):

Employer (if any):

Recreational activities:

 
 

It may take a moment to submit your information. Please wait for a confirmation message.

 
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WEO Media, 8625 SW Cascade Avenue Suite 300, Beaverton, OR, 97008 - Key Phrases: dental marketing; dental SEO; dental websites; (888) 788-4670; www.weomedia.com; 5/20/2019