First Name
Middle Name
Last Name
Chart #
IN CASE OF AN EMERGENCY, please contact (name/relation)
Phone #
INSTRUCTIONS: Answer all questions and fill in the blank spaces when indicated. Answers to the following questions are for our records only and will be kept confidential.
Why are you here today?
When was your last visit to a dental office?
When were your last x-rays taken?
Are those x-rays available?
If YES, please write down PRIOR DENTIST NAME and PHONE NUMBER.
1. Are you in poor health?
2. Has there been any change in your general health within the past year?
3. My last physical was on
4. Are you currently under the care of a physician?
If so, what is the condition being treated?
5. The name, address and phone number of my physician:
6. Have you had any serious illness or operation?
If so, what was the illness or operation?
7. Have you been hospitalized or had serious illness within the past five years?
If so, what was the problem?
8. Do you have or have you had any of the following diseases or problems:
A. Damaged heart valves or artificial heart valves
B. Congenital heart lesions or murmurs
C. Cardiovascular disease (heart trouble, heart attack, coronary insufficiency, coronary occlusion, high blood pressure, arteriosclerosis, stroke)
1) Do you have pain in the chest upon exertion
2) Are you ever short of breath after mild exercise
3) Do your ankles swell?
4) Do you get short of breath when you lie down, or do you require extra pillows when you sleep?
5) Do have a cardiac pacemaker?
D. Sinus trouble
E. Asthma
F. Allergy
G. Hives or skin rash
H. Fainting spells or seizures
I. Diabetes
1) Do you urinate (pass water) more than 6 times a day?
2) Are you thirsty much of the time?
3) Does your mouth frequently become dry?
J. Hepatitis, jaundice or liver disease
K. Arthritis
L. Inflammatory rheumatism (painful, swollen joints)
M. Stomach ulcers
N. Kidney trouble
O. Tuberculosis
P. Do you have a persistent cough or cough up blood
Q. Low blood pressure
R. Venereal disease
S. Do you have:
9. Have you had abnormal bleeding associated with previous extractions, surgery, or trauma?
A. Do you bruise easily?
B. Have you ever required a blood transfusion?
If so, explain the circumstances
10. Do you have any blood disorder such as anemia?