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PATIENT NAME ________________________________________________ REG# _____________________ Please CIRCLE the appropriate response next to each question below: Yes (Y), No (N), Don’t Know (?) Do you have or have you had any of the following: Explain: _______________________________ Explain: _______________________________ 2. Heart or circulation problems? Explain: _______________________________ Explain: _______________________________ Explain: _______________________________ 8. Stomach, liver or intestinal problems? Explain: _______________________________ a. Stroke or transitory ischemic attack Explain: _______________________________ Explain: _______________________________ EXAMINER’S COMMENTS __________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ University of Michigan School of Dentistry 9. Allergic reactions or other problems? 10. Blood or immune system problems? h. Frequent nosebleeds, increased bruising or bleeding j. Have you had chemotherapy or radiation treatment? k. Other problems with the blood or immune system? Explain: _________________________________________ 11. What medications or other substances are you taking or have you taken in the past 2 months? a. Please list all prescription and non-prescription drugs including aspirin, birth control pills, herbal medications or other supplements. Write “none” if you are not taking any medications or other substances. _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ b. Have you ever taken the drugs Fenfluramine(Fen-phen), Pondimin, or Dexfenfluramine(Redux)? Y c. Have you taken or are you taking drugs to control bone loss? (ie. Fosamax®) a. Have you ever been hospitalized, had major surgery or been seriously hurt? If yes, what type and when___________________________________________________________ b. Have you had or do you have any sexually transmitted diseases (syphilis, gonorrhea, herpes, etc.)? c. Do you need any special accommodations for dental treatment? e. Have you ever used tobacco products? f. Are you currently using tobacco products? W hat type and how often ________________________________________________________ g. How many alcohol containing drinks do you consume a week? ____________ h. Do you use or have you used recreational drugs? i. Have you ever had a problem with alcohol and/or drugs? k. When was your last visit to a physician (medical doctor)? ___________________________________________ l. Do you have a physician (medical doctor)? If yes, please provide the Name, Address and Telephone _________________________________________ ____________________________________________________________________________ EXAMINER’S COMMENTS __________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ University of Michigan School of Dentistry 10. Blood or immune system problems? 1. What is the reason for your dental visit? ________________________________________ _________________________________________________________________ 2. Have you ever had any problems following dental treatment? If yes, please explain ____________________________________________________ 3. Have you ever had a bad or unusual reaction to local anesthetic? h. Frequent nosebleeds, increased bruising or bleeding 4. Have you ever had a severe injury to your face, teeth or jaws? j. Have you had chemotherapy or radiation treatment? 5. Have you ever had surgery in your mouth or on your lips? k. Other problems with the blood or immune system? 6. Have you ever had periodontal treatment to your gums? Explain: _________________________________________ 7. Have you ever had orthodontic treatment to straighten your teeth? 8. Have you ever had extraction (pulling) of any teeth? 9. Have you ever had endodontics (root canals) on any teeth? 10. Have you had any missing teeth replaced by a removable denture, fixed 11. Have you ever worn a bitesplint/nightguard? 13. Are your teeth sensitive to hot, cold or pressure? 17. Do you have difficulty opening your mouth as wide as you would like? 18. Do your jaw joints or muscles hurt? 19. Does your jaw click, pop or lock when you chew? 21. Do you have sores in or around your mouth? 22. Please circle the amount of sugar in your diet. 23. When was the last time your teeth were cleaned at a dental office? _________________________ 24. How often do you brush? __________________________________________________25. How often do you use dental floss? ____________________________________________26. Are you satisfied with the appearance of your teeth? If No, Why not? ________________________________________________________ 27. Do you have any questions, concerns, or additional information you would If Yes, please specify? ____________________________________________________ __________________________________________________________________ 28. How do you feel about going to the dentist (please circle) EXAMINER’S COMMENTS ____________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ University of Michigan School of Dentistry

Source: http://www.dent.umich.edu/sites/default/files/departments/patientservices/HHFormDEN004_0.pdf