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

HEALTH HISTORY FORM