chuyangdental.com- Health History Form

Email

example@example.com

Today’s Date

As required by law, our office adheres to written policies and procedures to protect the privacy of information about you that we create, receive or maintain. Your answers are for our records only and will be kept confidential subject to applicable laws. Please note that you will be asked some questions about your responses to this questionnaire and there may be additional questions concerning your health. This information is vital to allow us to provide appropriate care for you. This office does not use this information to discriminate.

Name

First NameMiddle NameLast Name

Home Phone

Area CodePhone Number

Business/Cell Phone

Area CodePhone Number

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Occupation

Height

Weight

Date of Birth

Sex

MF

SS# or Patient ID

Emergency Contact

First NameLast Name

Relationship

Home Phone

Area CodePhone Number

Cell Phone

Area CodePhone Number

If you are completing this form for another person, what is your relationship to that person?

Your Name

First NameLast Name

Relationship

Do you have any of the following diseases or problems:

	Yes/No/DK
Active Tuberculosis
Persistent cough greater than a 3 week duration
Cough that produces blood
Been exposed to anyone with tuberculosis

If you answer yes to any of the 4 items above, please stop and return this form to the receptionist.

Dental Information

For the following questions, please select your responses to the following questions.

	Yes/No/DK
Do your gums bleed when you brush or floss?
Are your teeth sensitive to cold, hot, sweets or pressure?
Is your mouth dry?
Have you had any periodontal (gum) treatments?
Have you ever had orthodontic (braces) treatment?
Have you had any problems associated with previous dental treatment?
Is your home water supply fluoridated?
Are you currently experiencing dental pain or discomfort?
Do you have earaches or neck pains?
Do you have any clicking, popping or discomfort in the jaw?
Do you brux or grind your teeth?
Do you have sores or ulcers in your mouth?
Do you wear dentures or partials?
Do you participate in active recreational activities?
Have you ever had a serious injury to your head or mouth?

Do you drink bottled or filtered water?

YesNoDK

If yes, how often?

DAILYWEEKLYOCCASIONALLY

Date of your last dental exam:

What was done at that time?

Date of last dental x-rays:

What is the reason for your dental visit today?

How do you feel about your smile?

Medical Information

Please mark (X) your response to indicate if you have or have not had any of the following diseases or problems.

Are you now under the care of a physician?

YesNoDK

Physician Name

First NameLast Name

Phone Number

Area CodePhone Number

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Are you in good health?

YesNoDK

Has there been any change in your general health within the past year?

YesNoDK

If yes, what condition is being treated?

Date of last physical exam

Have you had a serious illness, operation or been hospitalized in the past 5 years?

YesNoDK

If yes, what was the illness or problem?

Are you taking or have you recently taken any prescription or over the counter medicine(s)?

YesNoDK

If so, please list all, including vitamins, natural or herbal preparations and/or dietary supplements:

Do you wear contact lenses?

YesNoDK

Joint Replacement

Have you had an orthopedic total joint (hip, knee, elbow, finger) replacement?

YesNoDK

Date

If yes, have you had any complications?

Are you taking or scheduled to begin taking an antiresorptive agent (like Fosamax®, Actonel®, Atelvia, Boniva®, Reclast, Prolia) for osteoporosis or Paget’s disease?.

YesNoDK

Since 2001, were you treated or are you presently scheduled to begin treatment with an antiresorptive agent (like Aredia® , Zometa® , XGEVA) for bone pain, hypercalcemia or skeletal complications resulting from Paget’s disease, multiple myeloma or metastatic cancer?

YesNoDK

Date Treatment began

Do you use controlled substances (drugs)?

YesNoDK

Do you use tobacco (smoking, snuff, chew, bidis)?

YesNoDK

If so, how interested are you in stopping?

VERYSOMEWHATNOT INTERESTED

Do you drink alcoholic beverages?

YesNoDK

If yes, how much alcohol did you drink in the last 24 hours?

If yes, how much do you typically drink i n a week?

WOMEN ONLY

Are you Pregnant?

YesNoDK

Number of weeks

Taking birth control pills or hormonal replacement?

Nursing?

Allergies

Are you allergic to or have you had a reaction to: To all yes responses, specify type of reaction.

	Yes/No/DK
Local anesthetics
Aspirin
Penicillin or other antibiotics
Barbiturates, sedatives, or sleeping pills
Sulfa drugs
Codeine or other narcotics
Metals
Latex (rubber)
Iodine
Hay fever/seasonal
Animals
Food
Other

	Yes/No/DK
Artificial (prosthetic) heart valve
Previous infective endocarditis
Damaged valves in transplanted heart

Congenital heart disease (CHD)

	Yes/No/DK
Unrepaired, cyanotic CHD
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.

	Yes /No/DK
Cardiovascular disease
Angina
Arteriosclerosis
Congestive heart failure
Damaged heart valves
Heart attack
Heart murmur
Low blood pressure
High blood pressure
Other congenital
heart defects
Mitral valve prolapse
Pacemaker
Rheumatic fever
Rheumatic heart disease
Abnormal bleeding
Anemia
Hemophilia
AIDS or HIV infection
Arthritis
Autoimmune disease
Rheumatoid arthritis
Systemic lupus
erythematosus
Asthma
Bronchitis
Emphysema
Sinus trouble
Tuberculosis
Cancer/Chemotherapy/ Radiation Treatment
Chest pain upon exertion
Chronic pain
Diabetes Type I or II
Eating disorder
Malnutrition
Gastrointestinal disease
G.E. Reflux/persistent
heartburn
Ulcers
Thyroid problems
Stroke
Glaucoma
Hepatitis, jaundice or
liver disease
Epilepsy
Fainting spells or seizures
Sleep disorder
Do you snore?
Kidney problems
Night sweats
Osteoporosis
Persistent swollen glands
in gland
Severe headaches/migraines
Severe or rapid weight loss
Sexually transmitted disease
Excessive urination

Blood transfusion:

YesNoDK

If yes, date:

Neurological disorders

YesNoDK

Mental health disorders

YesNoDK

Specify:

Recurrent Infections.

YesNoDK

Type of infection

Has a physician or previous dentist recommended that you take antibiotics prior to your dental treatment?.

YesNoDK

Name of physician or dentist making recommendation:

First NameLast Name

Phone Number

Area CodePhone Number

Do you have any disease, condition, or problem not listed above that you think I should know about?.

YesNoDK

Please explain:

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

Signature of Dentist

Date

FOR COMPLETION BY DENTIST

Comments: