When visiting a healthcare provider or undergoing a new treatment, patients are often asked to complete a Medical History Form. This essential document provides a comprehensive overview of an individual's health, capturing everything from personal to family medical history. The form typically starts with basic personal information, including date of birth, gender, weight, and height. It delves into general medical and dental histories, asking about overall health status, any changes in health over the past year, and details about any current treatments or medications. Important aspects like major hospitalizations, surgeries, allergies, and even lifestyle habits such as exercise and tobacco or alcohol use are covered to give healthcare providers a full picture of the patient's health. For women, it includes specific questions about pregnancy status or menopause. Additionally, the form asks about past and present symptoms across various systems in the body, from cardiovascular to neurological issues. Recognizing the significance of family health history, patients are also asked to disclose any genetic diseases or other conditions present within their family. This document plays a crucial role in guiding healthcare professionals to deliver personalized and effective care, highlighting the importance of accuracy and completeness when patients fill it out.
| Question | Answer |
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| Form Name | Medical History Form |
| Form Length | 4 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 1 min |
| Other names | printable medical history form template, health history form example filled out, online medical history form, medical history form template |
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NAME: |
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DATE: |
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CHART: |
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UNIVERSITY OF WASHINGTON SCHOOL OF DENTISTRY - MEDICAL AND DENTAL HISTORY |
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GENERAL INFORMATION |
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1. a. Date of Birth: ____ |
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b. Gender: |
Male |
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c. Weight: ______ lbs. |
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Year |
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Female |
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d. Height: ____ ft. ____ inches |
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e. Highest grade of regular school that you have completed? _________ |
f. Employed? |
Yes |
No |
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GENERAL MEDICAL INFORMATION |
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2. |
Please rate your health. |
Excellent |
Very Good |
Good |
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Fair |
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Poor |
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3. |
Has there been a change in your general health in the past year? |
Yes |
No |
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4. |
Your Physician: |
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City_____________________ |
Phone No.: _______________________ |
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5. |
Date of last physical examination: Month _____Year ______ Currently under treatment by a physician? |
Yes No |
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Please explain______________________________________________________________________________ |
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6. |
Do you engage in regular exercise? |
Yes |
No Type____________________________________________ |
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7. |
Do you need to take antibiotics prior to receiving dental or surgical care? |
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Yes |
No |
Don’t know |
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MAJOR HOSPITALIZATIONS, SURGERIES, AND BLOOD TRANSFUSION MARK HERE IF NONE VERIFIED BY EXAMINER
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DATE (Month/Year) |
REASON |
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______ |
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_________________________________________________________________________________________________________ |
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_________________________________________________________________________________________________________ |
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_________________________________________________________________________________________________________ |
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ALLERGIC OR UNUSUAL REACTION TO ANY OF THE FOLLOWING? |
MARK HERE IF NONE |
VERIFIED BY |
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EXAMINER |
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9. |
Penicillins |
Opiates/codeine |
Other drugs: |
Other substances (food, metals, etc.) |
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Sulfa drugs |
Iodine |
List: 1. ____________________ |
List: 1. |
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Aspirin |
Latex |
2. ____________________ |
2. ___________________________ |
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Local anesthesia |
3. ____________________ |
3. ___________________________ |
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Type of Reaction ________________________________________________________________________________________ |
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WOMEN ONLY |
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NOT APPLICABLE |
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10. |
Are you |
PREGNANT? ____ weeks? |
Trying to become pregnant? |
Not sure if you are pregnant? |
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Using birth control pills ____________________ |
Going through menopause? |
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(Name of Prescription) |
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PRESCRIPTION/ NON PRESCRIPTION MEDICATIONS |
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MARK HERE IF NONE |
VERIFIED BY |
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(Use continuation page if necessary) |
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EXAMINER |
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11. List all medications and herbal supplements/remedies that you are currently taking. |
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Name: |
For what Condition? |
Dose/Frequency of use: |
A)
B)
C)
D)
E)
F)
\\peg\dns\ocs\forms\medical history form.doc 11/01
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GENERAL MEDICAL INFORMATION - PRESENT SYMPTOMS
12. Mark symptom(s) that you NOW experience or HAVE RECENTLY experienced. |
MARK HERE IF NONE |
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VERIFIED BY EXAMINER |
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GENERAL |
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HEAD & NECK |
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Neck pain________________________________________ |
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Weight loss_______ Lbs. Over what time period? _________ |
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Neck lump/swelling_________________________________ |
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Weight gain_______ Lbs. Over what time period? _________ |
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Headache________________________________________ |
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Loss of appetite ____________________________________ |
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Facial pain _______________________________________ |
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Always hungry _____________________________________ |
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Jaw pain_________________________________________ |
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Always thirsty ______________________________________ |
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Frequent urination___________________________________ |
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Fatigue ___________________________________________ |
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SALIVARY |
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Faint easily ________________________________________ |
Need liquid to swallow dry foods______________________ |
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Night sweats_______________________________________ |
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Bleed easily _______________________________________ |
Mouth feels dry when eating a meal____________________ |
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Bruise easily_______________________________________ |
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CARDIOVASCULAR |
Difficulties swallowing any foods______________________ |
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Shortness of breath with exertion_______________________ |
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Sense of too little saliva_____________________________ |
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Racing or irregular heart beat__________________________ |
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Sense of too much saliva____________________________ |
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Swollen ankles _____________________________________ |
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Cold ankles/feet ____________________________________ |
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Chest pain/angina___________________________________ |
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EYES |
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Vision changes____________________________________ |
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RESPIRATORY |
Dry eyes_________________________________________ |
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Coughing spell_____________________________________ |
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Wheezing_________________________________________ |
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EARS |
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Use 2 or more pillows to sleep_________________________ |
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Hearing loss______________________________________ |
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MUSCULOSKELETAL_ |
Ringing ears______________________________________ |
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Joint pain _________________________________________ |
Earaches ________________________________________ |
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Swollen joints ______________________________________ |
Pressure/stuffiness in ears___________________________ |
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Muscle cramping____________________________________ |
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SKIN CHANGES |
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NOSE/THROAT |
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Congested/runny nose______________________________ |
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Skin problems_____________________________________ |
Nose bleeds ______________________________________ |
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Nail changes______________________________________ |
Nasal obstruction __________________________________ |
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NEUROLOGICAL |
Sore throat _______________________________________ |
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Hoarseness/voice changes __________________________ |
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Numbness/tingling__________________________________ |
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Mouth breathing/ snoring ____________________________ |
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Paralysis/weakness_________________________________ |
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Memory changes___________________________________ |
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Smell/taste changes_________________________________ |
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PAIN |
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Difficulty chewing___________________________________ |
Back pain________________________________________ |
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Swallowing changes_________________________________ |
Other pains ______________________________________ |
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Speech changes____________________________________ |
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Dizzy spells or fainting_______________________________ |
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BEHAVIORAL |
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GASTROINTESTINAL |
Stress___________________________________________ |
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Sleep difficulties___________________________________ |
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Indigestion ________________________________________ |
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Feel depressed ___________________________________ |
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Reflux/heartburn____________________________________ |
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Nausea/vomiting____________________________________ |
Feel agitated/anxious_______________________________ |
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Bowel problems____________________________________ |
Other ___________________________________________ |
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FAMILY MEDICAL HISTORY MARK HERE IF NO ONE IN YOUR FAMILY |
VERIFIED BY |
HAS EVER HAD ANY OF THE PROBLEMS LISTED BELOW |
EXAMINER: |
13. Darken the circle beside medical problems that have been present in your parents, brothers/sisters, or close relatives.
Genetic (inherited) disease _________________________ |
Bleeding disorders ____________________________ |
Liver/kidney disease______________________________ |
Tuberculosis___________________________________ |
Immune system disease ___________________________ |
Neurologic disease______________________________ |
Diabetes________________________________________ |
Other (include cancer)____________________________ |
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\\peg\dns\ocs\forms\medical history form.doc 11/01
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MEDICAL HISTORY - PAST AND PRESENT ILLNESS
14.Darken the circle for illnesses that you CURRENTLY HAVE or HAVE HAD IN THE PAST
Cancer & Neoplastic Disease
Cancer_______________________________________
Leukemia/Lymphoma ___________________________
Genetic (inherited) Disease
Type_________________________________________
Immune System Disorder
Rheumatoid arthritis_____________________________
Lupus erythematosus____________________________
Sjogren’s Syndrome_____________________________
Other_________________________________________
Hormonal or Metabolic Disorders Diabetes______________________________________
Thyroid problems _______________________________
Adrenal insufficiency_____________________________
Other_________________________________________
Heart/Blood Disorders
High blood pressure_____________________________
Artherosclerosis________________________________
Heart attack ___________________________________
Coronary artery disease__________________________
Heart murmur__________________________________
Heart valve problems____________________________
Bleeding disorder_______________________________
Anemia_______________________________________
Other ________________________________________
Neurological Disorders
Epilepsy/Seizures_______________________________
Neuralgia _____________________________________
Stroke________________________________________
Other_________________________________________
Chronic Pain
Back _________________________________________
Abdominal_____________________________________
Headache/Migraine _____________________________
Other_________________________________________
Head and Neck Conditions
Injury to face, jaws, neck _________________________
Concussion____________________________________
Radiation treatment _____________________________
Temporomandibular joint disease __________________
Salivary gland problems__________________________
Sinusitis ______________________________________
Glaucoma_____________________________________
Other ________________________________________
MARK HERE IF NONE
VERIFIED BY EXAMINER
Gastrointestinal Disorders
Ulcer/Gastritis____________________________________
Irritable bowel syndrome/Colitis ______________________
Other___________________________________________
Lung/Airway Disorders
Emphysema_____________________________________
Pneumonia______________________________________
Bronchitis_______________________________________
Asthma_________________________________________
Tuberculosis_____________________________________
Sleep Apnea_____________________________________
Other___________________________________________
Skin Disorders
Skin cancer______________________________________
Skin infections ___________________________________
Other___________________________________________
Other Major Organ Disease
Kidney disease___________________________________
Liver disease_____________________________________
Organ transplant__________________________________
Spleen surgery___________________________________
Other __________________________________________
Infectious Diseases
Rheumatic fever__________________________________
Strep Throat_____________________________________
Mononucleosis___________________________________
Hepatitis________________________________________
HIV/AIDS _______________________________________
Other___________________________________________
Behavioral Conditions
Psychiatric illness_________________________________
Anxiety/Panic attacks______________________________
Depression______________________________________
Suicide attempt or thoughts _________________________
Other___________________________________________
Habits/Addiction
Drug abuse______________________________________
Alcohol abuse____________________________________
Other Conditions
Disabled ________________________________________
Prosthetic valve __________________________________
Prosthetic joint ___________________________________
DOCTOR’S/ STUDENT’S USE
(Please write comments about positive responses on lines adjacent to item and use this space as needed):
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\\peg\dns\ocs\forms\medical history form.doc 11/01
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15.CONSUMPTION OF BEVERAGES AND OTHER SUBSTANCES
a.Number of caffeinated beverages you drink in a day:
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5+ |
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b. Number of alcoholic beverages you drink in a week: |
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0 |
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d. Number of carbonated beverages a day: |
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0 |
5+ |
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c. Currently using any street or recreational drugs? |
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No |
Yes (Type?)________________________ |
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MARK HERE IF NONE |
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VERIFIED BY EXAMINER |
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e. |
Have you ever used tobacco? |
No |
Yes |
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If yes, what type: |
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Cigarette |
Pipe/Cigar |
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Smokeless |
f. |
Do you currently use tobacco? |
No |
Yes |
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If yes, average number of uses per day: ______ |
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For how many years? ____ |
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16.DENTAL HISTORY : Darken the circle beside items that describe your past dental problems and dental care.
Regular dental care |
Occasional dental care |
Wisdom tooth extractions |
Orthodontics |
Gum disease (pyorrhea, gingivitis or periodontal disease)
Treatment for jaw trauma/fracture (Type?)_______________________________________________________________
Had an adverse reaction to dental treatment (Please describe)_______________________________________________
Dental fears or anxiety______________________________________________________________________________
17. Rate your ORAL HEALTH in general. |
Excellent |
Very Good |
Good |
Fair |
Poor |
18. How good a job do you feel you are doing in taking care of your oral health?
Excellent Very Good Good Fair Poor
19. Date of last regular dental visit: ___ ____ Name and address of dentist: _____________________________
Month Year |
_____________________________ |
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FAMILY DENTAL HISTORY
20. Darken the circle beside oral problems that have been present in your parents, brothers/sisters, or close relatives.
Caries |
Gum disease (pyorrhea, gingivitis or periodontal disease) |
Dry Mouth |
TMJ disorder |
DOCTOR’S/ STUDENT’S USE
Additional Notes or Comments:
Patient’s Signature_______________________________________________Date____________
Reviewed by (Student)___________________________________________________
Date____________
Reviewed by (Faculty) ___________________________________________________
Date____________
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\\peg\dns\ocs\forms\medical history form.doc 11/01