Form

*Deerhaven Family Dentistry Medical Health History *

Patient First Name

Patient Last Name

Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions.

Emergency Contact Name/ Phone#

Comment

Who is your primary physician? and phone #

Comment

Who is your previous dentist?

Comment

Whom may we thank for referring you?

Comment

Date of last physical exam?

Comment

Have you been hospitalized in the past five years? If yes, why?

If Yes

Medications

Do you take, or have you used, Phen-Fen or Redux?

Do you take bone density medications? Check all that apply

Actonel

Aredia

Atelvia

Boniva

Binosto

Didronel

Donefoe

Fosamax

Reclast

Skelid

Zometa

If other please list

If Yes

Are you taking any blood thinners?

Asprin

Coumadin/Warfarin

Eliquis

Heparin

Pradaxa

Xarelto

If other please list

If Yes

Are you allergic to:

Penicillin

Clindamycin

Metal Sensitivity

Latex

Tetracycline

If other please list

If Yes

Are you taking any medications? if so please list

If Yes

Do you use Tobacco?

If yes - How long? How much and what type?

If Yes

Do you use controlled substances?

If Yes

Women: Are you...

Do you have, or have you had, any of the following?

AIDS/HIV Positive

Steroid Medicine

Hemophilia

Radiation Treatments

Alzheimer's Disease

Diabetes

Drug/Alcohol Addiction

Hepatitis B or C

Anemia

Herpes

High Blood Pressure

Epilepsy or Seizures

Artificial Heart Valve

Excessive Bleeding

Artificial Joint

Hypoglycemia

Asthma

Fainting Spells/Dizziness

Sinus Trouble

Breathing Problems

Stroke

Bruise Easily

Cancer

Chemotherapy

Mitral Valve Prolapse

Chest Pains

Heart Attack/Failure

Osteoporosis

Tuberculosis

Cold Sores/Fever Blisters

Heart Murmur

Pain in Jaw Joints

Congenital Heart Disorder

Ulcers

Heart Trouble/Disease

Psychiatric Care

Do you have any physical or medical conditions not listed aboved?

If Yes

Dental History

Do you have specific problems?

If Yes

Has fear of discomfort kept you from dental visits?

Do your gums bleed?

Do you clench or grind your teeth?

Have you ever had...

Injury to Face, Jaws or Teeth

Oral Surgery

Orthodontics

Periodontal (gum) Treatment

Do you take fluoride supplements? (children)

Do you have a Medical Power of Attorney?

If Yes

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in medical status.

Patient, Parent or Guardian