Health history (sample a)

Patient’s Name :________________________________Date of Birth:__________Height:______Weight:_______ Age:________
Physician Name:_______________________Dentist Name:___________________Orthodonist Name:____________
Reason for Visit: ________________________ How were you referred to us?_______________ Date:___________
Answer all questions by circling Yes (Y) or No (N) All responses are kept confidential

Are you taking or have you ever taken Bisphospho-
nates for osteoporosis, multiple myeloma or other cancers (Reclast, Fosamax, Actonel, Boniva, 4. Are you now under a physician’s care for K. Have you ever been advised not to take a medication? 5. Have you ever had any serious illnesses,
L. Please list any and all medications taken, including
operations or hospitalizations? If so, describe:. Y N prescription medications, diet drugs, over-the-counter medications, herbal or holistic remedies, vitamins or 6. DO YOU HAVE OR HAVE YOU EVER HAD:
A. Rheumatic Fever or Rheumatic Heart Disease? . Y N 8. ARE YOU ALLERGIC TO OR HAVE YOU HAD AN
C. Cardiovascular Disease (Heart Attack, Heart ADVERSE REACTION TO:
Trouble, Heart Murmur, Coronary Artery Disease, A. Local Anesthesia (Novacaine, etc.)? . Y N Angina, High Blood Pressure, Stroke, Palpitations, B. Antibiotics (Penicillin, Erythromycin, etc.)? . Y N Heart Surgery, Pacemaker)? ………………………Y N D. Lung Disease (Asthma, Emphysema, COPD, Chronic Cough, Bronchitis, Pneumonia, Tuberculosis, E. Seizures, Convulsions, Epilepsy, Fainting or H. Chemicals or jewelry (rash or sensitivity)? . Y N F. Bleeding Disorder, Anemia, Bleeding Tendency, Please list ALL allergies and/or reactions? . Y N
Blood Transfusion? Do you bruise easily? . Y N G. Liver Disease (Jaundice, Hepatitis)? . Y N 10. Is there any past history of Alcohol or Chemical Dependency or Emotional Disorder that may affect 11. Have you had any serious problems associated with O. Implants placed anywhere in your body 12. Have you or an immediate family member had any (Heart Valve, Pacemaker, Hip, Knee)? . Y N problem associated with intravenous anesthesia? . Y N P. Radiation (X-ray) treatment for Cancer? . Y N 13. Do you have any other disease, condition or Q. Clicking or popping of jaw joint, pain near ear, problem not listed above that you think the doctor difficulty opening mouth, grind or clench teeth? . Y N 14. Do you wish to talk to the doctor privately S. Any disease, drug or transplant operation that has depressed your immune system? . Y N 15. Have you ever had a bone density scan? . Y N 7. ARE YOU USING ANY OF THE FOLLOWING:
A. Are you Pregnant, or is there any chance
B. Anticoagulants (Blood Thinners)? . Y N C. Methadone or Suboxone treatment? ……………. Y N C. If you are using Oral Contraceptives, it is important
E. High Blood Pressure medications? . Y N that you understand that antibiotics (and some other F. Steroids (Cortisone, Prednisone, etc.)? . Y N medications) may interfere with the effectiveness of oral contraceptives. Therefore, you will need to use H. Insulin or Oral Anti-Diabetic drugs? . Y N mechanical forms of birth control for one complete cycle Digitalis, Inderal, Nitroglycerin or other heart drug? Y N of birth control pills, after the course of antibiotics or other medication is completed. Please consult with your physician for further guidance. I understand the importance of a truthful and complete Health History to assist my dentist in providing the best care possible. I
have had the opportunity to discuss my Health History with my dentist.

Signature of Person Completing Health History


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