Patient History Online Form Medical and Dental Form SubmissionSubmit Your Medical and Dental Information Patient's Name: Today's Date: Address: Date of Last Visit: Date of Med. History: City: State: Zip: Email: Home Phone: Work Phone: Birth Date: Social Security No: Marital Status: Employer: Your Cell Phone #: Emergency Contact: Emergency Contact #: Who referred you? Name of other family members seen here: Pharmacy: Parent / Guardian: Sex: Male FemaleIf Female, please answer the following: Are you taking birth control pills? Yes No Are you pregnant? Yes No If Yes, # of weeks: Are you nursing? Yes No Do you smoke or use tobacco? Yes No Height: Weight: Check any of the following conditions you have had: Abnormal Bleeding Alcohol Abuse Anemia Arthritis Artificial Heart Valve Artificial Joints Asthma Blood Transfusion Bruise Easily Cancer-Chemotherapy Colitis Diabetes Difficulty Breathing Drug Abuse Emphysema Epilepsy Fainting Spells Fever Blisters Frequent Headaches Glaucoma Heart Attack Heart Murmur Heart Surgery Hemophilia Hepatitis A Hepatitis B High Blood Pressure HIV+ AIDS Kidney Problems Liver Disease Low Blood Pressure Mitral Valve Prolapse Night Sweats Pain in Jaw Joints Pace Maker Pneumocystitis Pre-Med Required Psychiatric Problems Radiation Therapy Rheumatic Fever Seizures Sickle Cell Disease Sinus Problems Stroke Taken Fen-Phen Thyroid Problems Tuberculosis Ulcers Venereal Disease Yellow JaundiceCheck any allergies you have: Aspirin Codeine Dental Anesthetics Erythromycin Jewelry Latex Metals Penicillin TetracyclineDental History:Do you have a specific dental problem? Yes No If Yes, describe: Do you have dental examinations on a routine basis? Yes No Last Visit: Do you think you have active decay or gum disease? Yes No If Yes, describe: Do you brush and floss on a routine basis? Yes No Discuss: Do your gums ever bleed? Yes No Discuss: Do you like your smile? Yes No Why? Does your food catch between your teeth? Any loose teeth? Yes No Describe: Do you want to keep your remaining teeth? Yes No Discuss: Do you ever have clicking, popping, or discomfort in the jaw joint? Do you brux or grind? Yes No Describe: Have your past experiences in a dental office always been positive? Yes No Discuss: Do you smoke or chew? Any sores or growths in the mouth? Yes No Discuss: Medical History: Are you under a physician's care now? Yes No Why? Who? Phone: Have you ever been hospitalized or had a major operation? Yes No Discuss: Have you ever had a serious head or neck injury? Yes No Discuss: Are you taking any medications, pills, or drugs? Yes No What? Are you on a special diet? Yes No Discuss:
