Patient Health History Update

CONFIDENTIAL HEALTH HISTORY
Patient Name:*

PrefixFirst NameMiddle NameLast NameSuffix
Date of Birth:*

MonthDayYear
Date
Gender*

MaleFemaleGender FluidOther
Please Answer the following questions:
Is your general health good?*

YESNO
If NO, explain:
Has there been a change in your health within the last year?*

YESNO
if YES, explain:
Have you gone to the hospital or emergency room or had a serious illness in the last three years?*

YESNO
if YES, explain:
Are you being treated by a physician now, including annual wellness checkups?*

YESNO
Reason for exam:
Date of last medical exam?

MonthDayYear
Date
Physician's Name
Physician's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Have You Ever Experienced Any of the Following? (check all that apply)

Chest Pain/AnginaFainting SpellsRecent weight lossNight SweatsPersistent CoughCoughing up bloodBleeding ProblemsBlood in stoolsDiarrhea or constipationFrequent UrinationDifficulty UrinatingRinging in EarsHeadachesDizzinessBlurry VisionFrequent vomitingJaundiceDry MouthExcessive thirstDifficulty swallowingSwollen anklesJoint pain or stiffnessShortness of breathOther
Explanation
If you checked any of the above
Have you ever had or do you have any of the following? (check all that apply)

Heart DiseaseFamily history of heart diseaseHeart attackArtificial JointsStomach problems or ulcersHeart DefectsAIDS/HIVSurgeriesHospitalizationDiabetesFamily history of diabetesTumors or cancerHeart murmursRheumatic FeverSkin DiseaseHardening of arteriesHigh blood pressureSeizuresCosmetic SurgeryChemotherapyRadiationArthritis, rheumatismLiver DiseaseEye DiseaseStrokeTransplantsEating DisordersTuberculosisPsychiatric careOsteoporosisThyroid DiseaseAsthemaHepatitisSexually transmitted diseasesHerpesCanker or cold soresAnemiaOther
Explanation
If you checked any of the above
Are you allergic to any of the following? (check all that apply)

Codeine or other opioidsPenicillin or other antibioticsNitrous oxideLocal anestheticLatexOther
Explanation
If you checked any of the above
Are you taking or have you taken any of the following in the last three months? (check all that apply)

Recreational drugsOver-the-counter medicinesWeight loss medicationsAnti depressantsOpioids (e.g., Norco, Vicodin, Percocet, Percodan)Tobacco in any form (including e-cigarettes/vaping)AlcoholBisphosphonate (Fosamax)Herbal SupplementsAntibioticsSupplementsAspirinOther
Explanation
If you checked any of the above
Are you currently taking any prescription medications?*

YESNO
Please list all prescription medications
Please provide as much detail as possible, including dosage. If you cannot remember your doctor may ask you to provide a list after your appointment.
Are you or could you be pregnant?*

YESNO
if YES, what month?
Are you taking birth control pills or other medical birth control?*

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

YESNO
if YES, please explain:
Have you ever been pre-medicated for dental treatment?*

YESNO
if YES, why:
Have you ever taken Fen Phen for weight loss?*

YESNO
Have you ever taken Fen Phen? if YES, when:
Is there any other issue or condition that you would like to discuss with the dentist in private?*

YESNO
Whom would you like us to contact in case of an emergency?
Name:
Relationship:
Phone Number:
The practice of dentistry involves treating the whole person. If the dentist determines that there may be a potentially medically compromised situation, medical consultation may be needed prior to commencement of dental treatment.

If necessary, I authorize Dela Rama Dental to contact my physician.
I certify that I have read and understand this form. To the best of my knowledge, I have answered every question completely and accurately. I will inform my dentist of any change in my health and/or medication. Further, I will not hold my dentist, or any other member of his/her staff, responsible for any errors or omissions that I may have made in the completion of this form.
Signature of Patient (Parent or Guardian)

Clear
Date

MonthDayYear
DateHourMinutesAM/PM Option
Should be Empty:

CONFIDENTIAL HEALTH HISTORY