• 240-288-9999

    Patient Form

    Health History Form

    As required by law, our office adheres to written policies and procedures to protect the privacy of information about you that we create, receive or maintain. Your answers are for our records only and will be kept confidential subject to applicable laws. Please note that you will be asked some questions about your responses to this questionnaire and there may be additional questions concerning your health. This information is vital to allow us to provide appropriate care for you. This office does not use this information to discriminate.

    Note: Appointment reminder will be send by text

    If you are completing this form for another person, what is your relationship to that person?

    Yes No Dk
    Active Tuberculosis
    Persistent cough greater than a 3 week duration.
    Cough that produces blood
    Been exposed to anyone with tuberculosis.

    Step 1/5

    Dental Information

    Yes No Dk
    Do your gums bleed when you brush or floss?
    Are your teeth sensitive to cold, hot, sweets or pressure?
    Does food or floss catch between your teeth?
    Is your mouth dry?
    Have you had any periodontal (gum) treatments?
    Have you ever had orthodontic (braces) treatment?
    Have you had any problems associated with previous dental treatment?
    Is your home water supply fluoridated?
    Do you drink bottled or filtered water?
    If yes, how often? Select one: DAILY / WEEKLY / OCCASIONALLY
    Are you currently experiencing dental pain or discomfort?
    Yes No Dk
    Do you have earaches or neck pains?
    Do you have any clicking, popping or discomfort in the jaw?
    Do you brux or grind your teeth?
    Do you have sores or ulcers in your mouth?
    Do you wear dentures or partials?
    Do you participate in active recreational activities?
    Have you ever had a serious injury to your head or mouth?
    Date of your last dental exam:
    Date of last dental x-rays:

    Step 2/5

    Medical Information

    Check DK For Unknown Yes No Dk
    Are you now under the care of a physician?
    Are you in good health?
    Has there been any change in your general health within the past year?
    Yes No Dk
    Have you had a serious illness, operation or been hospitalized in the past 5 years?
    Are you taking or have you recently taken any prescription or over the counter medicine(s)?
    Yes No Dk
    Do you wear contact lenses?
    Joint Replacement:
    Have you had an orthopedic total joint (hip, knee, elbow, finger) replacement?
    Date:
    Are you taking or scheduled to begin taking either of the medications, alendronate (Fosamax®) or risedronate (Actonel®)for osteoporosis or Paget’s disease?
    Since 2001, were you treated or are you presently scheduled to begin treatment with the intravenous bisphosphonates (Aredia® or Zometa®) for bone pain, hypercalcemia or skeletal complications resulting from Paget’s disease, multiple myeloma or metastatic cancer?
    Allergies - Are you allergic to or have you had a reaction to: To all yes responses, specify type of reaction.
    Local anesthetics
    Aspirin
    Penicillin or other antibiotics
    Barbiturates, sedatives, or sleeping pills
    Sulfa drugs
    Codeine or other narcotics
    Yes No Dk
    Do you use controlled substances (drugs)?
    Do you use tobacco (smoking, snuff, chew, bidis)?
    Do you drink alcoholic beverages?
    WOMEN ONLY:
    Pregnant?
    Taking birth control pills or hormonal replacement?
    Nursing?
    Yes No Dk
    Metals.
    Latex (rubber).
    Iodine.
    Hay fever/seasonal.
    Animals.
    Food.
    Other.

    Step 3/5

    Please Check on Yes No (or) Dk your response to indicate if you have or have not had any of the following diseases or problems.

    Yes No Dk
    Artificial (prosthetic) heart valve.
    Previous infective endocarditis.
    Damaged valves in transplanted heart.
    Congenital heart disease (CHD):
    Unrepaired, cyanotic CHD.
    Repaired (completely) in last 6 months.
    Repaired CHD with residual defects.

    Except for the conditions listed above, antibiotic prophylaxis is no longer recommended for any other form of CHD.

    Yes No Dk
    Autoimmune disease.
    Rheumatoid arthritis.
    Systemic lupus erythematosus.
    Asthma
    Bronchitis
    Emphysema
    Sinus trouble
    Tuberculosis
    Cancer/ Chemotherapy/ Radiation Treatment
    Yes No Dk
    Hepatitis, jaundice or liver disease.
    Epilepsy.
    Fainting spells or seizures.
    Neurological disorders.
    Sleep disorder
    Mental health disorders.
    Yes No Dk
    Cardiovascular disease.
    Angina.
    Arteriosclerosis.
    Congestive heart failure .
    Damaged heart valves.
    Heart attack.
    Heart murmur.
    Low blood pressure.
    High blood pressure.
    Other congenital heart defects.
    Yes No Dk
    Mitral valve prolapse.
    Pacemaker.
    Rheumatic fever.
    Rheumatic heart disease.
    Abnormal bleeding.
    Anemia.
    Blood transfusion.
    Hemophilia.
    AIDS or HIV infection.
    Arthritis.
    Yes No Dk
    Chest pain upon exertion.
    Chronic pain.
    Diabetes Type I or II.
    Eating disorder.
    Malnutrition.
    Gastrointestinal disease.
    G.E. Reflux/persistent heartburn.
    Ulcers.
    Thyroid problems.
    Stroke.
    Glaucoma.
    Yes No Dk
    Recurrent Infections.
    Kidney problems.
    Night sweats.
    Osteoporosis.
    Persistent swollen glands in neck.
    Severe headaches/migraines.
    Severe or rapid weight loss.
    Sexually transmitted disease.
    Excessive urination.
    Verify

    Step 4/5

    Yes No Dk
    Has a physician or previous dentist recommended that you take antibiotics prior to your dental treatment?
    Do you have any disease, condition, or problem not listed above that you think I should know about?

    Note:  Both Doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment.

    I certify that I have read and understand the above and that the information given on this form is accurate. I understand the importance of a truthful health history and that my dentist and his/her staff will rely on this information for treating me. I acknowledge that my questions, if any, about inquiries set forth above have been answered to my satisfaction. I will not hold my dentist, or any other member of his/her staff, responsible for any action they take or do not take because of errors or omissions that I may have made in the completion of this form.

    Signature of Patient/Legal Guardian:

    Verify
    Why Choose Us
    Our Services
    Contact Us

    ©2022 MontgomeryDentalMD.All rights reserved.| Makers Mind