DENTAL MEDICAL HISTORY HEALTH QUESTIONAIRE
Name: ___________________________________________________________________ D.O.B. ______/______/________ Sex: m M
m F m O
Address: __________________________________________________________ City: _________________________________ Zip:____________
Home phone: (____) _____-________ Fax: (____) _____-________ Other: (____) _____-___________
Who gives consent: ___Self or Name: ________________________________________________________________ Relationship: _______________
Phone: (____) _____-_________ Address: _____________________________________________________________________________________
Best contact for appointments: ____________________________________________________________________
Phone: (____) _____-________
Primary care provider: ___________________________________________________________________________ Phone: (____) _____-________
Pharmacy:___________________________________________________________________________________
Phone: (____) _____-________
DEVELOPMENTAL DIAGNOSES: ______________________________________________________________________________________________
MEDICAL DIAGNOSES (list all, even those not treated with medication): ____________________________________________________________________
______________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________
MAJOR MEDICAL CURRENTLY NOT TREATED: ____________________________________________________________________________________
MEDICATIONS: (Include any prescribed, over the counter, or herbal medications, including PRN):
NAME
DOSAGE
REASON TAKING
______________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________
ALLERGIES: _____________________________________________________________________________________ LATEX:
m Yes m No
SURGERIES: (include dates): _____________________________________________________________________________________
____________________________________________________________________________________________________________
ANY HISTORY OF THE FOLLOWING (check all that apply):
m heart surgery, attack, or infection: _____________________________________________________________date: __/__/______
m medications for bones (anti-reclast medications/bisphosphonates): __________________________________________________
how long: ____________________ oral or IV: ______ date last administered: __/__/____
m bleeding problems or blood thinners? __________________________________________ INR value: ___ date: ___/___/_______
m cancer, chemotherapy, radiation tx: site(s): ___________________________________________________ date: __/__/_______
__ PICA
m stroke date: __/__/____
m Hepatitis Type: ___
m SIB: ____________________________________________________________________
m Tuberculosis
m cerebral shunt
WEIGHT: ____ lbs or ____ kgs
m Apnea __Y__N CPAP machine
m regular m cut< 0.5 inch m pureed m liquids only m G-TUBE: m with oral m other:________________________________
m Yes m No Tolerates liquids m Thickened liquids only Aspiration Risk: m high m medium m low
DIET:
COMMUNICATION: m verbal
m non-verbal m limited verbalization m sign language m device: ___________________________________
other: _________________________________________________________________________________________________________________
AMBULATION: m unassisted
wheelchair:
m Yes
m gait belt m walker m Hoyer lift m other: __________________________________________________
m No transfers
m Yes m No needs assistance to transfer
PICA= an abnormal desire to eat substances eating substances not normally eaten SIB= self-injurious behavior