Date of last dental cleaning (Month/Year): Date of last radiograph (Month/Year): Current sensitivity? Yes No □ □ Hot/Cold Yes No Chewing Yes No Air Yes No □ □ □ □ □ □ Length of time Area: Left Right Left Right □Upper □Upper □Lower □Lower Dental Implants? Yes No □ □ Family history of gum/periodontal disease? Yes No □ □ Do you clench/grind? Yes No □ □ PAST/CURRENT MEDICAL CONDITION Patient Initials DOB Mark symptoms that you have now or have recently experienced. Mark here if none □ GENERAL SOCIAL Bruise easily Bleed easily Drink alcoholic beverages □ □ □ Faint easily Anxious Use recreational drugs □ □ □ Other Other □ □ HEART AND BLOOD CONDITIONS IMMUNE Blood pressure HIV/AIDS □ □ Heart disease Rheumatoid arthritis □ □ Heart attack Lupus erythematosus □ □ Heart surgery Sjogren’s Syndrome □ □ Valve replacement □ □ Pacemaker □ Heart murmur HORMONE □ Bleeding disorder □ Anemia Diabetes Type □ □ Hemophilia Thyroid Type □ □ Other Adrenal insufficiency □ □ □ RESPIRATORY SALIVARY Asthma Emphysema □ □ Tuberculosis Pneumonia of too little saliva □ □ □ Sleep Apnea Other_____________ Sense of too much saliva □ □ □ Mouth feels dry when eating a meal □ NEUROLOGICAL Difficulties swallowing any foods □ Other □ Stroke Seizures □ □ Epilepsy Convulsions OTHER □ □ Paralysis Memory changes □ □ Other Kidney disease Liver disease □ □ □ Organ transplant Hepatitis □ □ MUSCULOSKELETAL Herpes Jaundice □ □ Hip, Knee or Joint Replacement □ Arthritis pain or swelling Glaucoma Port Catheter □ □ □ □
Date of last dental cleaning (Month/Year): Date of last radiograph (Month/Year): Current sensitivity? □ Yes □ No Hot/Cold □ Yes □ No Chewing □ Yes □ No Air □ Yes □ No Length of time Area: □Upper Left □Upper Right □Lower Left □Lower Right Dental Implants? □ Yes □ No Family history of gum/periodontal disease? □ Yes □ No Do you clench/grind? □ Yes □ No PAST/CURRENT MEDICAL CONDITION Patient Initials DOB Mark symptoms that you have now or have recently experienced. □ Mark here if none GENERAL □ Bruise easily □ Bleed easily □ Faint easily □ Anxious □ Other HEART AND BLOOD CONDITIONS □ Blood pressure □ Heart disease □ Heart attack □ Heart surgery □ Valve replacement □ Pacemaker □ Heart murmur □ Bleeding disorder □ Anemia □ Hemophilia □ Other RESPIRATORY □ Asthma □ Emphysema □ Tuberculosis □ Pneumonia □ Sleep Apnea □ Other_____________ NEUROLOGICAL □ Stroke □ Seizures □ Epilepsy □ Convulsions □ Paralysis □ Memory changes □ Other MUSCULOSKELETAL □ Arthritis □ pain or swelling SOCIAL □ Drink alcoholic beverages □ Use recreational drugs □ Other IMMUNE □ HIV/AIDS □ Rheumatoid arthritis □ Lupus erythematosus □ Sjogren’s Syndrome □ HORMONE □ Diabetes Type □ Thyroid Type □ Adrenal insufficiency □ SALIVARY □ of too little saliva □ Sense of too much saliva □ Mouth feels dry when eating a meal □ Difficulties swallowing any foods □ Other OTHER □ Kidney disease □ Liver disease □ Organ transplant □ Hepatitis □ Herpes □ Jaundice □ Hip, Knee or Joint Replacement □ Glaucoma □ Port Catheter
RegisDentalMedicalHistory.docx