HEALTH HISTORY

HEALTH HISTORY

Correct answers to the following questions will allow us to treat you on a more individual basis, providing the care appropriate for your particular needs.
Name
(First & Last Name)
Birth Date*

MonthDayYear
Date
Age*
Why are you now seeking dental treatment?*
Please answer each question below. Check yes or no. If in doubt, leave blank.
Are you in good health now?*

YESNO
Are you now under the care of a physician?*

YESNO
If so, what is the condition being treated
Have you ever been hospitalized or had a serious illness?*

YESNO
If yes, explain
Have you ever had excessive bleeding following an extraction?*

YESNO
Do cuts take a long time to heal?*

YESNO
(Woman) Are you pregnant? If so, give due date?
Do you use tobacco in any form? *
If yes, how much?
Do you have or have you ever had any of the following? Please indicate yes or no below.
GENERAL
Tire easily, weakness*

YESNO
EYES
Glaucoma*

YESNO
NOSE
Frequent nose bleeds*

YESNO
Sinus Problems*

YESNO
NERVOUS SYSTEM
Stroke*

YESNO
Headaches*

YESNO
Convulsions/epilepsy*

YESNO
HEART/BLOOD VESSELS
Heart Murmur*

YESNO
Chest pain/discomfort*

YESNO
Heart attack/trouble*

YESNO
Shortness of breath*

YESNO
High blood pressure*

YESNO
Congenital heart disease*

YESNO
Mitral valve prolapse*

YESNO
Artificial heart valve*

YESNO
Heart Surgery*

YESNO
Pacemaker*

YESNO
Rheumatic fever*

YESNO
BONES/MUSCLES
Arthritis/rheumatism*

YESNO
Artificial joints/limbs*

YESNO
DIGESTIVE SYSTEM
Hepatitis*

YESNO
Jaundice*

YESNO
Ulcers*

YESNO
URINARY
Kidney Disease*

YESNO
Venereal Disease*

YESNO
BLOOD
Bruise Easily*

YESNO
Anemia*

YESNO
Blood Transfusion*

YESNO
RESPIRATORY
Emphysema*

YESNO
Asthma/hay fever*

YESNO
Tuberculosis*

YESNO
ENDOCRINE
Diabetes*

YESNO
Family history of diabetes*

YESNO
Thyroid condition/goiter*

YESNO
OTHER
Radiation therapy*

YESNO
Chemotherapy*

YESNO
Tumors or growths*

YESNO
Cancer*

YESNO
HIV+/AIDS*

YESNO
Are you ALLERGIC or have you ever experienced any reaction to the following?
Local Anesthetics (novocaine, etc.)*

YESNO
Barbiturates/sedative/sleeping pills*

YESNO
Penicillin/other antibiotics*

YESNO
Aspirin or codeine*

YESNO
Sulfa drugs*

YESNO
Other Allergies
Does dental treatment make you nervous?*

NOSLIGHTLYMODERATELYEXTREMELY
If so, would you be interested in sedation dentistry?
Do you need to premedicate with an antibiotic prior to dental treatment?*

YESNO
If yes, what is the antibiotic and the dosage?
Are you taking any of the following?
Antibiotics/sulfa drugs*

YESNO
Blood Thinners*

YESNO
Blood pressure medication*

YESNO
Thyroid medication*

YESNO
Cortisone/steroids*

YESNO
Antihistamines/allergy drugs/cold remedies*

YESNO
Birth control pills*

YESNO
Insulin/other diabetic drugs*

YESNO
Recreational drugs*

YESNO
Heart medications*

YESNO
Nitroglycerin*

YESNO
Aspirin*

YESNO
Other Medication*

YESNO
If yes to any of the above, please list name of medication and dosage in space below:
Is there any disease, condition or problem not listed above that you think we should know about? If yes, please explain:
Have you ever had treatment for breast cancer or have you been treated with chemotherapeutic drugs and invenous Bisphonates? (Intravenous Bisphosphonates therapy, or bone-sparing drugs are commonly ued on the treatment of osteoporosis and metastatic bone cancer to help decrease associated pain and fractures following treatment for breast cancer.)*

YESNO
Physician’s Name*
Phone Number*
Ex: 610-123-4567
Have you ever had any serious trouble associated with previous dental treatment?
To the best of my knowledge, all of the preceding answers are true and correct. If I ever have any change in my health or change in my medication, I will inform the dentist at the next appointment.
Signature of Patient, Parent or Guardian*

Clear
Date*

MonthDayYear
Date
Should be Empty: