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Maplewood Oral and Maxillofacial Surgery, P.A. Patient Name ____________________________________________________ Date of Birth _________________ M □ F □ Dentist __________________________________________ Orthodontist (if applicable) _____________________________________ And Relationship _________________________________________________________ Phone_____________________________
If patient is a minor and parents are divorced, which parent has legal custody? ___Mother ___Father ___Joint*
*If Joint custody both parents must give consent for treatment per MN State Law. PATIENT HISTORY
What is the purpose of your visit? ________________________________________________________________________________ If applicable, please complete the following:
Difficulty with
Previous
Problem?
Chewing or Swallowing?
Injury to
this Area?
Have you received previous treatment for this problem? □ No □ Yes If yes, please complete the following: □ Surgery ___________________________________________________________________________________________________ □ Medications _______________________________________________________________________________________________ □ Other ____________________________________________________________________________________________________ Family History (list conditions pertinent to this problem) _____________________________________________________________
Social History: Tobacco Use ____________________ Alcohol Use _____________________ Occupation ____________________
REVIEW OF SYSTEMS
Pertinent Medical Questions
Is a physician currently treating you for any condition? □ Name of Physician __________________________ Are you currently taking any prescription, over-the-counter, or Physician’s Phone Number ____________________ herbal medications or any supplements? (If yes, please list in box at right) □ Name & Dose of Medications and Supplements Have you ever used marijuana, cocaine, heroine, ecstacy, meth, or other such drugs? Please list: ____________________________ □ ____________________________________________________ Do you or have you ever taken medications for Osteoporosis or Osteopenia like Fosamax, Actonel, Boniva, Reclast, etc.? Please list:__________________________________________________ □ _____________________________________________________ Have you ever had general anesthesia (going to sleep for a Have you or your immediate family member(s) ever had any unusual reactions to local anesthetic (Novocaine) or general ALLERGIC/IMMUNOLOGIC
Are you aware of any previous reactions or allergies to latex? Are you allergic to any drugs/medications? (Please Specify) □ □ ___________________________________________ Pertinent Medical Questions
RESPIRATORY
Do you have chest pains or shortness of breath? Do you have asthma or any other lung disease? Have you been diagnosed with sleep apnea? CARDIOVASCULAR
Do you have a heart murmur?
Do you bleed excessively when you cut yourself or are you currently taking a blood thinning medication? Do you have Anemia (thin blood) or any other type Have you been diagnosed with high blood pressure? DIGESTIVE
Do you suffer from stomach acid reflux?
GENITOURINARY
Do you have kidney problems?
Are you pregnant (or possibly pregnant)? ENDOCRINE
Do you have Diabetes (sugar disease)?
HEMATOLOGIC/LYMPHATIC
Have you ever had x-ray or cobalt treatments for Cancer
Have you received treatment for Cancer? (Please specify)
NEUROLOGIC
Do you have Epilepsy or seizures?
MUSCULOSKELETAL
Have you ever had back or neck injuries? (Please specify)
Have you ever had jaw joint pain or clicking; TMJ pain?

Source: http://www.maplewoodoms.com/pdf/medical-history-questionnaire-interactive.pdf