Dental health history



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DENTAL HEALTH HISTORY



Personal Information


Name: Date: I prefer to be called: Chart Number:





Birthday (MM/DD/YYYY): / /

Male _Female


Home Phone: ( ) Work Phone: ( ) Mobile Phone: ( ) Other Phone: ( ) List other family members that are seen in our dental clinic:

What was the date of your last dental visit? (MM/DD/YYYY): / /

Do you have any learning disabilities? YES NO (If yes, please list):

Do you use any assistive devices? (i.e. hearing aids, glasses) YES NO (If yes, please list):


What is the reason for your dental visit today? (i.e. cleaning, pain, routine visit, etc…):


Have you ever had a serious/difficult problem associated with any previous dental work? YES NO

(If yes, please explain):

Do you experience jaw joint discomfort (TMJ, TMD)? YES NO

How would you rate your current dental health? GOOD FAIR POOR How many times a day do you brush?

What type of tooth brush bristles do you use? SOFT MEDIUM HARD

Do you floss? YES NO (If yes, how many times a day?): Do you like to SMILE? YES NO

***In case of EMERGENCY, who should we contact?***



Name: Relationship: Home Phone: ( ) Work Phone: ( ) Mobile Phone: ( ) Other Phone: ( )






MEDICAL HISTORY

Do you have a personal physician? YES NO (If yes, who?): Office Phone: ( ) Date of last visit: / / How would you rate your current health? GOOD FAIR POOR

Is your physician treating you for a specific condition? YES NO (If yes, please explain):


Please list all current medications and dosages you are taking:

COFMC Medical Patients: we will access your medical chart with your permission to attain a list of your current medications. Please indicate this my initialing here: ____________, and you may bypass the above list.



FEMALES ONLY

Are you currently pregnant? YES NO (If yes, how many weeks?): Are you nursing? YES NO N/A


Are you taking birth control pills? YES NO


***REQUIRED FOR ALL PATIENTS***

CARDIOVASCULAR:

Heart Failure Heart disease/attack Angina pectoris chest pain High Blood Pressure


Low blood pressure Heart Murmur

Mitral valve prolapsed Rheumatic fever


Congenital heart defect Artificial heart valve Arrhythmias

Heart pacemaker/defibrillator


Heart transplant Heart surgery

Prior Phen-Fen use Stroke


Aneurysm Other Heart problems (Explain):


HEMATOLOGIC:

Blood transfusion Anemia

Sickle cell disease Tendency to bleed longer

Hemophilia

Leukemia





***REQUIRED FOR ALL PATIENTS CONTINUED***

NEURAL AND SENSORY:



Eye pain
Vision problems
Glaucoma or cataracts Earaches


Ringing in ears Hearing loss

Severe headaches

Fainting/dizziness


Epilepsy

Nervousness

Psychiatric treatment Developmental delay


GASTROINTESTINAL:


Stomach ulcers Gastritis

Liver disease Jaundice

Hepatitis (Circle one) HEP A HEP B HEP C


RESPIRATORY:


Hay fever Sinusitis

Chronic cough Emphysema

Supplemental oxygen

Colitis

Cirrhosis
Seasonal allergies

Tuberculosis (TB)

Persistent diarrhea


Asthma

Breathing difficulty (COPD)


ENDOCRINE:



Diabetes


Insulin-dependent (IDDM) Non-insulin dependent (NIDDM) Thyroid disease


Hyper-thyroidism Hypo-thyroidism


URINARY/SEXUALLY TRANSMITTED DISEASES:



Frequent urination Kidney problems


Bladder problems


HIV Positive


Sexually transmitted disease (STD)(List all that apply):



DERMAL/SKELETAL:


Latex allergy Abnormal mole

Stiff joints Arthritis

Mouth ulcers (canker sores)


Osteoporosis

Artificial joint


Sore muscles

Fever blisters








OTHER CONDITIONS:

Frequent sore throat Enlarged lymph node Tumor or cancer

Chemotherapy Surgical removal of tumor Alcohol use

Steroid therapy

Tobacco use (Circle one): Current Former Never

Radiation treatment

Drug addiction

(If yes): How many packs per day: How many years of use:

Other conditions (Please list):

***REQUIRED FOR ALL PATIENTS***



Please let us know if you have any drug allergies. (Check all that apply and list any not listed):





Aspirin

Codeine

Penicillin

Sulfa


Tetracycline Latex

Dental anesthetic:


Other (Please list):

If you have no known drug allergies (NKDA), please indicate with your initials and date:


Initials Date
I understand that the information I have provided today is correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence and it is my responsibility to inform Central Oklahoma Family Medical Center of any changes in my medical/dental status.
I authorize the dental staff to perform any necessary dental services that I may need during diagnosis and treatment with my informed consent.
By signing below, I acknowledge that at my triage (treatment planning) appointment, definitive treatment (extraction, filling, etc.) may or may not be rendered. I also understand that if I am more than 10 minutes late to my designated appointment time, my appointment may be rescheduled.
Patient (or Guardian, if under the age of 18) Signature: __________________Date: _________________

FOR CLINIC STAFF USE ONLY:

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