Confidential Health History

Confidential Health History
Patient Name*

First NameLast Name
An accurate and complete health history is critical in planning and performing proper care. All information is strictly confidential.
Physician's Name
Physician's Phone Number
Please enter a valid phone number.
Approximate date of last medical check up
Do you consider your health to be good?*

YesNo
Have you ever been hospitalized, had any serious illness or operation?*

YesNo
Please provide details if hospitalized, any serious illness or operation:
Are you presently taking any medications?*

Yes (If yes please list names and doses below)No
Current medications:
Are you allergic to latex gloves?*

YesNo
Are you allergic or have you reacted adversely to any medications?*

Yes (If yes please check below or provide examples)No
Allergies to medications:

PenicillinErythromycinTetracyclineClindamycinAspirinCodeinePercodanDemerolValiumSulfonamide (Sulfa)Local AnestheticsIodineSleeping PillsOther
Do you smoke or vape?*

Smoke cigarettesSmoke marijuanaVapeNONE OF THE ABOVEOther
If you smoke or vape, how much per day?
When you walk stairs or take a walk, do you ever have to stop because of...?

Pain in your chestShortness of breathBecause you are very tiredNONE OF THE ABOVE
FOR WOMEN ONLY: Are you pregnant?

YesNo
If you are pregnant, please provide your due date:
FOR WOMEN ONLY: Are you taking birth control pills?

YesNo

Do you have or have you ever had any of the following?:

	If YES please check	Provide details (if necessary)
Rheumatic fever?
Congenital heart disease?
Heart murmur and/or damaged heart valves?
Heart attack?
Congestive heart failure?
Pace maker, artificial valves or transplants?
Angina pectoris (pain in the chest)?
Heart surgery?
Breathing problems? (e.g. asthma, emphysema, etc.)
Tuberculosis?
High or low blood pressure?
Stroke?
Blood disorders? (e.g. anemia, hemophilia, prolonged bleeding, bruising)
Blood transfusions? If so, when?
Diabetes? If so, what type?
Thyroid excess or insufficiency?
Hepatitis, jaundice, or liver disease? If yes, please specify.
Kidney problems or dialysis?
Stomach or intestinal ulcers?
Digestive problems? (e.g. Crohn's disease)
Arthritis? If so what type and where in the body?
Artificial joints (knee or hip and when)?
Allergies or sensitivities?
Cancer or tumor? If so what type?
Radiation or chemotherapy?
AIDS or positive for HIV?
Cold sores?
Venereal disease? (e.g. syphilis, gonorrhea, etc.)
Fainting spells?
Epilepsy or convulsions?
Nervous disorders? (e.g. Parkinson's disease)
Psychiatric disorders?
Trauma to face or head?
Frequent headaches? If so, where?
Vision problems? (e.g. glaucoma)
Cosmetic surgery?
Sinus problems?
Hay fever?
Drug addiction?
Cortisone medication?
Sickle cell disease?
Scarlet fever?
Do you snore loudly (loud enough to be hears through closed doors or your bed-partner elbows you for snoring at night)?
Do you often feel tired, fatigued or sleepy during the daytime?
Has anyone observed you stop breathing / gasping during your sleep?

Are there any problems that have not been listed above?*

YesNo
Please provide details of any problems that have not been listed above:
Is there anything in this questionnaire that you did not understand?*

Yes (If necessary, provide details below)No
Please provide details:
Patient Certification*

I, the undersigned, certify that all of the above medical information is true to my knowledge and I have not omitted any pertinent information.
Name of parent / guardian signee (if applicable)
Signature*

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