Medical History Questionnaire
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- Blake Lamb
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1 Medical History Questionnaire OFFICE USE Patient ID: FORM DATE: / / NAME: DATE OF BIRTH: / / Allergens No known allergens Iodine Plastic Antibiotics Latex Sedatives Aspirin Local anesthetics Sleeping pills Barbiturates Metals Sulfa drugs Codeine Penicillin : Current Medications Medicine Dosage/Frequency Reason Significant Current Medical Condition Never Past Medical History Date / Note Significant Current Date / Note Medical Condition Never Past Acid reflux Bruising easily Anemia Cancer Atherosclerosis Chemotherapy Arthritis Chronic fatigue Asthma Chronic pain Autoimmune disorder COPD Bleeding easily Coronary heart disease Blood pressure - High Current pregnancy Blood pressure - Low Depression
2 Medical History Significant Current Date / Note Significant Current Date / Note Medical Condition Never Past Medical Condition Never Past Diabetes Mood disorder Difficulty sleeping Multiple sclerosis Dizziness Muscular dystrophy Emphysema Nasal allergies Epilepsy Neuralgia Fibromyalgia Osteoarthritis Glaucoma Osteoporosis Gout Parkinson's disease Heart attack Prior orthodontic treatment Heart murmur Psychiatric care Heart pacemaker Radiation treatment Heart valve replacement Rheumatic fever Hemophilia Rheumatoid arthritis Hepatitis Sinus problems Hypertension Sleep apnea Hypoglycemia Stroke Immune system disorder Ischemic heart disease (reduced blood supply) Tendency for ear infections Thyroid disorder Kidney problems Tuberculosis Liver disease Tumors Meniere's disease Urinary disorders Mitral valve prolapse Medical Condition Current Past Date / Note Medical Condition Current Past Date / Note
3 Family History Has any member of your family (parent, sibling, or grandparent) had: Cancer Diabetes Stroke Heart disease High blood pressure Sleep disorder Obesity Thyroid disorder Patient's Occupation Father snores Mother snores Father has sleep apnea Mother has sleep apnea Social History Employer Tobacco Use: Cigarettes Never smoked Current smoker # of packs per day # of years Quit When did you quit? tobacco: Pipe Cigar Snuff Chew Alcohol Use: Do you drink alcohol? Yes No If yes, # of drinks per week: Caffeine Intake: None Coffee/Tea/Soda # of cups per day: Additional: Regular exercise Patient Signature I authorize the release of a full report of examination findings, diagnosis, treatment program etc., to any referring or treating dentist or physician. I additionally authorize the release of any medical information to insurance companies or for legal documentation to process claims. I understand that I am responsible for all charges for treatment to me regardless of insurance coverage. Patient Signature: Date: I certify that the medical history information is complete and accurate. Patient Signature: Date:
4 Review of Systems OFFICE USE Patient ID: FORM DATE: / / NAME: DATE OF BIRTH: / / General Within Normal Limits Denied Appetite changes Denied Sensitivity to heat or cold Denied Marked weight change Denied Tires easily Denied Night sweating Denied Unusual weakness Denied Recent trauma or infection Denied Denied Head, Eyes, Ears, Nose and Throat Within Normal Limits Denied Dizziness Denied Sore throat or hoarseness Denied Headaches Denied Swallowing difficulties Denied Nose bleeding Denied Trauma Denied Ringing in ears Denied Ulcers or lumps in mouth Denied Sinus infections Denied Sore gums or tongue Denied Denied Lungs Within Normal Limits Denied Persistent cough Denied Wheezing Denied Shortness of breath Denied Swelling of ankles Denied Denied Heart Within Normal Limits Denied High blood pressure Denied Denied
5 Neurologic Denied Dizziness Denied Headaches Denied Muscle weakness or paralysis Denied Denied Reproductive Within Normal Limits Denied Impotence Denied Lack of sex drive Within Normal Limits Denied Denied Within Normal Limits Denied Denied Patient Signature I authorize the release of a full report of examination findings, diagnosis, treatment program etc., to any referring or treating dentist or physician. I additionally authorize the release of any medical information to insurance companies or for legal documentation to process claims. I understand that I am responsible for all charges for treatment to me regardless of insurance coverage. Patient Signature: Date: I certify that the medical history information is complete and accurate. Patient Signature: Date:
6 Version: TMDQUES1 Head, Neck and Facial Pain Questionnaire OFFICE USE Patient ID: NAME: CURRENT DATE: / / DATE OF BIRTH: / / MALE FEMALE Referring Physician: Contact ID: Number Frequency Intensity Number Frequency Intensity #1 = the most severe symptom #1 = the most severe symptom Jaw pain Morning head pain Jaw clicking Jaw locking Limited mouth opening Facial pain Neck pain Ringing in the ears Dizziness Nocturnal teeth grinding Frequent Heavy Snoring Pain when chewing Headaches Migraines : Write In HEAD PAIN Unsupported Control Unsupported Control Unsupported Control Unsupported Control Unsupported Control JAW PAIN Jaw pain - on opening Jaw pain - while chewing Symptoms Jaw popping Jaw locks closed Jaw locks open Jaw pain - at rest JAW SYMPTOMS Jaw clicking Teeth grinding MOUTH AND NOSE RELATED CONDITION
7 MOUTH AND NOSE RELATED CONDITION Burning tongue Frequent biting of cheek Frequent snoring Broken teeth Teeth clenching Dry mouth EAR RELATED CONDITIONS Buzzing in the ears Tinnitus (ringing in the ears) Ear pain Ear congestion Pain in front of the ear Hearing loss Recurrent ear infections Pain behind the ear Blurred vision Eye pain EYE RELATED CONDITIONS Pain or pressure behind the eyes Symptoms THROAT, NECK & BACK RELATED CONDITIONS CONTINUED Back pain - lower Back pain - middle Back pain - upper Chronic sore throat Constant feeling of a foreign object in throat Difficulty in swallowing Limited movement of neck Neck pain Numbness in the hands or fingers Sciatica Scoliosis Shoulder pain Shoulder stiffness Swelling in the neck Swollen glands Thyroid enlargement Tightness in throat Tingling in the hands or fingers Chronic sinusitis Is there anything that makes your pain or discomfort worse? History Of Symptoms If you have received treatment/diagnosis in the past, where was services received? Is there anything that makes your pain or discomfort Yes No Are you currently being treated for TMD?
8 better? What other information is important regarding the pain or condition? If being treated where are you receiving treatment? Have you been treated/diagnosed for TMD before? Yes No History Of Treatment Practitioner's Name Specialty Treatment Approximate Date History Of Accident COMPLETE THIS SECTION IF YOU WERE INVOLVED IN AN ACCIDENT OR A TRAUMATIC INCIDENT RELATED TO THE CURRENT VISIT: DATE OF ACCIDENT OR INCIDENT: Enter date (month/day/year) THE PATIENT BELIEVES THE CAUSE OF THE PAIN OR CONDITION TO BE: A motor vehicle accident A motorcycle accident A work related incident A playground incident An athletic endeavor A fight A fall Select one: Hit by an object Hit an object An illness An injury Orthodontics Dental procedures Whiplash : An accident History Of Accident
9 COMPLETE THIS SECTION IF YOU WERE INVOLVED IN AN ACCIDENT OR A TRAUMATIC INCIDENT RELATED TO THE CURRENT VISIT: WERE YOU: Select one: A passenger in a motor vehicle The driver of a vehicle A pedestrian HISTORY OF ACCIDENT Did you fall? Were you hit by an object? Did you hit an object? : At work IF IN A VEHICLE, WHERE WAS THE VEHICLE HIT? At the front end At the rear end At the front right area At the front leftt area Head on On driver's side On passenger's side area: At the rear right area At the rear left area INDICATE IF THERE WAS ANY TRAUMA: The patient's: Forehead Face Chin Top of head Teeth Jaw Side of head : Back of head Forcibly struck the: Steering wheel Windshield Passenger's side window Driver's side window Passenger's side door Headreast Seat Roof Interior of the car : Driver's side door Pain Qualities Head Pain History
10 --- LOCATION --- Which side are the headaches worse? Pain Qualities both sides the left side the right side Head Pain History --- LOCATION --- Headaches on a 0-10 Pain Scale Neck Pain on a Numeric Pain Scale Headache spreads to the temple the back of the head the temple the back of the head the forehead FREQUENCY Seconds --- SEVERITY ON A SCALE OF Minutes --- 0=No Pain 10=Worst Pain Imaginable --- Hours Jaw Pain on a Numeric Pain Scale Days Weeks When having pain do you experience: Facial Pain on a 0-10 Pain Scale occasional (0-3/mo) frequent (3-6/mo) constant --- DURATION --- Dizziness Double vision Fatigue Nausea Sensitivity to light (photophobia) Sensitivity to noise Throbbing Vomiting Burning DRAW YOUR PAIN PATTERNS FOLLOWING THIS KEY
11 Enter any text to appear below the image: Patient Signature I authorize the release of a full report of examination findings, diagnosis, treatment program etc., to any referring or treating dentist or physician. I additionally authorize the release of any medical information to insurance companies or for legal documentation to process claims. I understand that I am responsible for all charges for treatment to me regardless of insurance coverage.
12 Patient Signature: I certify that the medical history information is complete and accurate. Patient Signature: Date: Date:
Medical History Questionnaire
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