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)
Email Address*
example@example.com
Birthdate*

MonthDayYear
Age*
Why are you now seeking dental treatment?*
Please answer each question below. Check yes or no.
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?
example: yes, 1/1/20
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 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 to any of the above, please list name of medication and dosage in space below:
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 diabetes 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 below:
example: Tylenol, Vitamins, Baby Aspirin
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 intravenous Bisphosphonates? of osteoporosis and metastatic bone cancer to help decrease associated pain and fractures following treatment for breast cancer
Have you ever had treatment for breast cancer or have you been treated with chemotherapeutic drugs and intravenous Bisphonates? (Intravenous Bisphosphonates therapy, or bone-sparing drugs are commonly used 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*
Physician's Phone Number*
ex: 123-456-7890
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
Today's Date*

MonthDayYear
Should be Empty:

HEALTH HISTORY