Quality Resource Guide
l
Medical Health History in Dental Practice 6th Edition
10
Form 2
MetLife
Health History Interview
University of the Pacific
Patient Name:
______________________________
Name of Patient’s Physician: __________________________________ Physican’s Phone: ___________________
Significant Medical Findings
Dental Management Considerations
Date
Record below the number and details of any YES
A. yes / no
Cardiovascular
responses noted on the Health History, plus details
B. yes / no
Infectious diseases
of any YES responses to questions A through F.
C. yes / no
Allergy to medicines
D. yes / no
Hematologic, bleeding
E. yes / no
Medications
F. yes / no
Other medical problems not asked?
______________
________________________________________________________________
Date
Doctor’s Signature
This Health History Interview form is created and maintained by the University of the Pacific, Arthur A. Dugoni School of Dentistry, San Francisco, California
Support for the translation and dissemination of the Health Histories comes from MetLife Dental.