Fillable Madison College Medical Dental History (Madison Area Technical College)

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Madison College Medical Dental History (Madison Area Technical College)

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The Madison College Medical Dental History (Madison Area Technical College) form is 4 pages long and contains:

  • 0 signatures
  • 105 check-boxes
  • 115 other fields

Country of origin: US
File type: PDF

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Date:
Madison College Medical Dental History
Patient Name:
Family Status:Gender:
Birth Date:
Email Address:
Phone:
Address:
Emergency Contact Name/Phone #:
1705 Hoffman Street
Madison, WI 53704
608-258-2400
Last First MI Preferred Name
Title:
Mr/Ms/Mrs/etc
Male Female Other Married Single Child Other
Mobile Work Ext
Address 1
City State Zip Code
If yes, please indicate which condition(s) from the list below and include year of diagnosis.
Page 1 of 4
Are you now or have you ever been under a physician's care for any of the following conditions? Yes No
Allergies
Anemia
Arthritis
Artificial Heart Valve
Artificial Joints
Asthma
Back Problems
Cancer
Cardiovascular
Chemical Dependency
Chemotherapy
COPD/Emphysema
Diabetes
Eating Disorder
Epilepsy
Excessive Bleeding
Fainting
GERD/Digestive Issues
Glaucoma
Growths/Tumors
Head Injuries
Headaches
Heart Disease
Hemophilia
Hepatitis
High Blood Pressure
HIV/AIDS
Immunocompromised
Jaw Pain
Kidney Disease
Liver Disease
Mental Health Disorder
Mononucleosis
Nervous Disorder
Osteoporosis
Pacemaker
Pregnancy
Radiation Treatment
Rheumatic Fever
Scarlet Fever
Shortness of Breath
Sinus Problems
Skin Problems
STDs
Stroke
Swelling of Feet
Thyroid Problems
Tuberculosis
Vertigo, Tinnitus, or Ear Pain
Other
Year of diagnosis.
Any other conditions? Yes No
If yes, please explain and include the year of diagnosis.
Are you allergic to any of the following? Check all that apply
Do you use any of the following?
Please list any prescription medications, over-the-counter medications, vitamins/minerals or herbal remedies you are taking.
Name of Medication Reason Taken Adverse Reactions Dosage
If yes, please explain and include the year of diagnosis:
Have you ever been hospitalized, had an operation or a serious illness? Yes
No
If yes, please explain:
Do you now or have you ever required pre-medication for dental treatment? Yes
No
Are you pregnant or nursing? Yes No
Page 2 of 4
Acrylic
Aspirin
Codeine or other narcotics
Iodine
Latex
Local Anesthetic
Metals
Penicillin Drugs
Red Dye
Sulfites
Tetracycline Drugs
Tree Nuts
Other
If yes, please describe the reaction(s):
If yes, how often are you using these products?
Please list your current primary Physician's/Specialist's names locations & phone numbers:
ASA StatusToday’s Blood Pressure RAS LAS/
Alcohol
Cigarettes/Cigars
Hookah
Marijuana
Smokeless/Chewing Tobacco
Vapor Cigarettes
Please answer the following questions regarding your dental history.
When was your last dental cleaning/exam?
When was the last time you had dental x-rays?
Have you ever been treated for periodontal/gum disease? Yes
No
Have you ever had local anesthetic? Yes No
Do you have dental implants? Yes No
Page 3 of 4
Do you have or have you ever had any of the following?
Canker Sore
Cold Sore/Fever Blister Unhealed Mouth Sore
Do you now or have you ever lived in an area with fluoridated water?
If so, from what ages?
Yes No
Have you had any serious trouble associated with any previous dental visit?
If yes, please explain.
Yes No
If yes, did you have any reactions or symptoms from local anesthetic?
If yes, please describe:
At the present time, do you have any dental concerns? Yes
No
What is your dentist's name/address/phone?
Which dental products do you use at home?
How often?
How often? How often?
Manual ToothbrushDental Floss Toothpick
How often? How often? How often?
Mouth RinseElectric Toothbrush Tongue Cleaner
How often? How often? How often?
Oral IrrigatorInterdental Cleaner Other
Please check any of the following oral habits that you have:
Grinding your teeth
Mouth breathing Thumb sucking/Pacifiers
Nail biting
Other
Clenching your teeth
Chewing on pens, pencils, bobby pins, other objects
Page 4 of 4
Signature of Patient/Guardian Date
Reviewed by Student Instructor Dentist
Do you snack during the day? Yes No
If yes, how often daily?
1x
2x 3x
* By checking this box, I acknowledge that the information I provided is accurate to the best of my knowledge and I will inform my
clinician if any changes occur.
What snack/beverage items do you consume?
Fruits
Gum/Mints (sugar or sugar-free)
Nuts/Seeds
Soda (regular or diet)
Candy/Cookies
Cheese
Chips/Crackers
Coffee/Tea with sugar
Energy Drinks
Yogurt
Sports Drinks
Vegetables
Other
Date
Health Changes
CURRENT MEDICATIONS
1.
2.
3.
4.
Patient’s Signature
Today’s BP
Faculty InitialsStudent Initials
Date
Health Changes
CURRENT MEDICATIONS
1.
2.
3.
4.
Patient’s Signature
Today’s BP
Faculty InitialsStudent Initials
Date
Health Changes
CURRENT MEDICATIONS
1.
2.
3.
4.
Patient’s Signature
Today’s BP
Faculty InitialsStudent Initials
Medical and Dental History Update
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Madison College Medical Dental History (Madison Area Technical College)

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Completed 10 October 2020

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