Health History

Last Name First Middle

Height Weight Date of Birth Gender

For the following questions, please select Yes, No or Don't Know, whichever applies!

Do you have any of the following diseases or problems: If you answer yes to any of the 4 items, please contact the receptionist!

	Active Tuberculosis		Cough that produces blood
	Persistent cough grater than 3-week duration		Have you been exposed to anyone with tuberculosis?

Dental Information


	Do your gums bleed when you brush?		Have you ever had orthodontic (braces) treatment?
	Are your teeth sensitive to cold, hot, sweets, or pressure?		Do you have headaches, earaches or neck pains?
	Have you had any periodontal (gum) treatments?		Do you have any clicking, popping or discomfort in the jaw?
	Do you have sores or ulcers in your mouth?		Do you brux or grind your teeth?
	Does food or floss catch between your teeth?		Do you wear dentures or partials?
	Do you drink bottled or filtered water?		Is your home water supply fluoridated?
	If yes, how often?		Is your mouth dry?
	Do you participate in active recreational activities?		Have you ever had a serious injury to your head or mouth?
	Have you had a serious/difficult problem associated with any previous dental treatment? If so explain:

Reason for today's visit	Date of your last dental exam
Date of last dental x-rays	What was done at that time?
How do you feel about the appearance of your teeth?

Medical Information

	Are you in good health?
	Has there been any change in your general health within the past year? If yes, what condition are you being treated for?

	Are you now under the care of a physician? If yes, what is/are the condition(s) being treated?

Date of last physical examination

Physician(s) Name		Phone		Address		City, ST, Zip
Physician(s) Name		Phone		Address		City, ST, Zip

	Have you had any serious illness, operation, or been hospitalized in the past 5 years? If so, what was the illness or problem?
	Are you taking or have you recently taken any medication(s) including non-prescription medicine? If so, what medicine(s) are you taking?
	Prescribed
	Over the Counter
	Natural or herbal preparations
	Are you taking, or have you taken, any diet drugs such as Pondimin (fendluramine), Redux (dexphenfluramine) or phen-fen (phentemine)?
	Do you drink alcoholic beverages? If yes, how much alcohol did you drink in the last 24 hours?
	If yes, how much do you typically drink in a week?
	Are you alcohol and/or drug dependant? If so, have you received treatment?
	Do you use drugs or other substances for recreational purposes? If yes, please list
	Frequency of use (daily, weekly, etc.)Number of years of recreational drug use
	Do you use tobacco (smoking, snuff, chew)? If so, how interested are you in stopping?
	Do you wear contact lenses?
	Are you taking or scheduled to begin taking either the medications, alendronate (Fosamax) or risedronate (Actonel) for osteoporosis or Paget's disease?
	Since 2001, were you treated or are you presently scheduled to begin treatment with the intravenous bisphosphonates (Aredia or Zometa) for bone pain, hypercalcemia or skeletal complications resulting from Paget's disease, multiple myeloma or metastatic cancer?

WOMEN ONLY
	Are you pregnant? If yes, how many weeks?
	Taking birth control pills or hormonal replacement?
	Nursing?

DO YOU HAVE
	Artificial (prosthetic) heart valve?		Congenital heart disease (CHD)
	Previous infective endocarditis		Unrepaired, cyanotic CHD
	Damaged valves in transplanted heart		Repaired (completely) in last 6 months
			Repaired CHD with residual defects
Except for the conditions listed above, antibiotic prophylaxis is no longer recommended for any other form of CHD
	Have you had orthopedic total joint (hip, knee, elbow, finger) replacement?	If yes when was the operation done?
	Have you had any complications or difficulties with your prosthetic joint?	If yes, specify

Allergies -- Are you allergic to or have you had a reaction to: (Please answer all questions) To all "Yes" responses specify type of reaction.
	Local anesthetics		Latex
	Aspirin		Iodine
	Penicillin or other antibiotics		Hay Fever/seasonal
	Barbiturates, sedatives, or sleeping pills		Animals
	Sulfa Drugs		Food (Specify)
	Codeine or other narcotics		Metals
	Other (Specify)

Please indicate if you have or have had any of the following diseases or problems:

Abnormal Bleeding

Chronic Pain

Osteoporosis

AIDS or HIV infection

Persistent diarrhea

Persistent swollen glands in neck

Anemia

Autoimmune disease

Respiratory problems

Arthritis

Diabetes. If yes specify below

Rheumatoid arthritis

Severe or rapid weight loss

Asthma

Eating disorder

Sexual transmitted disease

Blood transfusion

If yes, date

Sinus trouble

If yes, date

Epilepsy

Sleep disorder

Cancer/chemotherapy/

Fainting spells or seizures

Stroke

radiation treatment

G.E. reflux

Systemic lupus erythematosus

Cardiovascular disease

Gastrointestinal disease

Thyroid problems

If yes, specify:

Glaucoma

Tuberculosis

Angina

Hemophilia

Ulcers

Arteriosclerosis

Hepatitis, jaundice or liver disease

Excessive urination

Congestive Heart Failure

Recurrent infections. Indicate

Do you have any disease, condition or problem not

Damaged heart valves

type of infection here:

listed above that you think I should know about? Explain:

Heart attack

Heart murmur

Kidney Problems

High blood pressure

Mental Health disorders - If yes, specify:

Low blood pressure

Mitral valve prolapsed

Malnutrition

Pacemaker

Migraines / severe headaches

Rheumatic heart disease

Night sweats

Rheumatic fever

Neurological disorders

Chest pain upon exertion

If yes, specify below

Has a physician or other dentist recommended you take antibiotics prior to dental treatment?

NOTE: Both doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment.
I certify that I have read and understand the above and that the information given on this form is accurate. I understand the importance of a truthful health history and that my dentist and his/her staff will rely on this information for treating me. I acknowledge that my questions, if any, about inquiries set forth above have been answered to my satisfaction. I will not hold my dentist, or any other member of his/her staff, responsible for any action they take or do not take because of errors or omissions that I may have made in the completion of this form.

_____________________________________________________________________
Signature of Patient/Legal Guardian Date

For Completion by Dentist / Auxiliary

Comments on patient interview concerning health history

Significant findings from questionnaire or oral interview

Dental management considerations

Signature of Dentist / Date

2.5/td>

07/09

HEALTH HISTORY FORM