Health History

Patient Name

Birth Date

I. Choose the appropriate answer (Leave Blank if you do not understand the question)

Is your general health good?

Has there been a change in your health within the last year?

Have you been hospitalized or had a serious illness in the last three years?

If yes, why?

Are you being treated by a physician now?

For what?

Date of last medical exam

Date of last dental exam

Have you had problems with prior dental treatment?

Are you experiencing any pain now?


II. Have you ever experienced:

Chest Pain (Angina)

Swollen Ankles

Shortness of breath

Recent weight loss, fever or night sweats

Persistent cough, coughing up blood

Bleeding problems, bruising easily

Sinus problems

Difficulty swallowing

Diarrhea, constipation, blood in stools

Frequent vomiting, nausea

Difficulty urinating, blood in urine

Dizziness

Ringing in ears

Headaches

Fainting spells

Blurred Vision

Seizures

Excessive Thirst

Frequent Urination

Dry mouth

Jaundice

Joint Pain, stiffness


III. Do you have or have you had:

Heart Disease

Heart Attack, Heart Defects

Heart Murmurs

Rheumatic Fever

Stroke, hardening of arteries

High Blood Pressure

Asthma, TB, Emphysema, other Lung Disease

Hepatitis, other Liver Disease

Stomach problems, ulcers

Family History of Diabetes, Heart Problem, Tumors

Psychiatric Care

Radiation Treatments

Chemotherapy

Prosthetic Heart Valve

Artificial Joint

Arthritis, Rheumatism

HIV+

Tumors, Cancer

Eye Disease, Skin Disease

Anemia

VD (Syphilis/Gonorrhea)

Herpes

Kidney or Bladder Disease

Thyroid or Adrenal Disease

Diabetes

Hospitalization

Blood Transfusions

Surgeries

Pacemaker

Contact Lenses


IV. Allergies:

Sulfa or Sulfur

Penicillin

Other Antibiotics

Latex

Foods or Chemicals


V. Are you taking:

Bisphosphonate Drugs such as Fosamax?

Recreational Drugs

Drugs, Medications, Over-the-Counter Medications (including Aspirin), or Natural remedies?

Tobacco in any form

Alcohol

Antibiotics

Pain Medications


VII. All Patients

Do you have or have had any other diseases or medical problems NOT listed on this form?

Do you require premedication with an Antibiotic prior to dental treatment?


VIII. Women Only

Are you or could you be pregnant or nursing?

Taking any birth control pills?

Printed Name

Initials (E-Signature)

Date

Services

Root Canal Therapy

Endodontic Retreatment

Apicoectomy

Cracked Teeth

Traumatic Injuries

Periodontal Procedures

Extraction/Implants

Schedule an Appointment

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