chatsworthsedationdentist-HEALTH HISTORY

HEALTH HISTORY
A MESSAGE ABOUT HEALTH HISTORIES AND DENTAL CARE: Although dentists primarily treat the mouth, head and neck areas, these areas all relate to your overall health. Therefore, it is important for us to know all facts relating to your present and past health. The information you give here is strictly confidential.
MEDICAL HEALTH HISTORY
Name of Physician (Medical Doctor)
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of your last MEDICAL examination:

MonthDayYear
Date
Are you now, or have you been under a physician’s care during the past two years?

YesNo
If yes, what conditions were you treated for?
Have you ever had any major illnesses or operations

YesNo
Please list and give approximate dates:
Do you now take, or have taken, any kind of drugs or medicines during the past year?

YesNo
If yes, please list:
Have you experienced any adverse or allergic reaction to penicillin, local anesthetic, codeine or other drugs?

YesNo
If yes, please list and explain:
Are you currently, or have in the past used a Biphosphanate for osteoporosis?

YesNo

Please review the following carefully and check any conditions for which you have been treated:

	YES	NO
Heart condition or murmur
Tuberculosis
Hepatitis or liver disease
Rheumatic fever
Pneumonia
Venereal disease/STD’s
Diabetes
Lung or respiratory disease Fainting/dizziness/nervous
High or low blood pressure
Glaucoma/eye problem
Convulsions/seizures
Kidney disorder
Arthritis/joint problem
Psychological problems
Cancer or tumors
Endocrine (gland) disorder
Fever/cold/canker sores
Bleeding or blood disorder
Asthma or hay fever
AIDS or HIV positive
Anemia
Stroke
Ulcers

Type a question

	Yes	No
If there was a simple, inexpensive way to whiten your teeth, would you be interested?
Would you like to keep your natural teeth healthy and pain free for as long as possible?
Does food catch between your teeth?
Do your gums feel irritated or swollen, or do they bleed frequently when brushing?
Have you ever been told that you have periodontal (gum) disease?
Have you ever been told that you have periodontal (gum) disease?
Do you frequently clench or grind your teeth, or do your jaws or jaw muscles feel tired?
Do you wear removable dentures (full or partial?
Are you aware if you have any adverse oral habits (tongue thrusting, lip or nail biting, etc.)

How often do you:


Brush?
Floss?
Go for regular cleanings and checkups?

HEALTH HISTORY