PATIENT INFORMATION, HEALTH HISTORY

PATIENT INFORMATION, HEALTH HISTORY

10800 Paramount Blvd # 304, Downey, CA 90241
Patient Name:*
E-mail:
Home Phone:*
Business / Cell Phone:
Address(Mailing Address):*

Street Address Line 2
Occupation:
Height:
Weight:
Date of Birth:*

MonthDayYear
Sex:*

MaleFemale
SS# or Patient ID:
Emergency Contact:
Relationship:
Home Phone:
Cell Phone:
If you are completing this form for another person, what is your relationship to that person?
Relationship:
How did you hear about us?

Do you have any of the following diseases or problems: (Select DK if you Don’t Know the answer to the the question)*

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

DENTAL INFORMATION

Do you have any of the following diseases or problems:*

	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
What is the reason for your dental visit today?*
How do you feel about your smile?*

MEDICAL INFORMATION
Are you now under the care of a physician?*

YesNoDK
Physician Name:
Phone:
Address:

Street Address Line 2
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:

MonthDayYear
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:

MonthDayYear
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:

MonthDayYear
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?

YesNoDK
Nursing?

YesNoDK

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:

Please select Yes/No/DK for your response to indicate if you have or have not had any of the following diseases or problems.*

	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 neck
Severe headaches/migraines
Severe or rapid weight loss
Sexually transmitted disease
Excessive urination

Blood transfusion:*

YesNoDK
If yes, date:

MonthDayYear
Neurological disorders*

YesNoDK
If yes, specify:
Mental health disorders:*

YesNoDK
If yes, 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:
Phone:
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 mydentist 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:*
Signature of Dentist:
Should be Empty: