silverspringdentalarts - Health History

HEALTH HISTORY
Today's Date

MonthDayYear
Name

First NameLast Name
Date of Birth

MonthDayYear
Email
(to be used only for dental/health related purposes)
PATIENT DENTAL HISTORY
Reason for today's visit
Date of last dental visit

MonthDayYear
Former Dentist
Date last dental X-rays

MonthDayYear
Check if you have had problems with any of the following:

Bad breathPeriodontal treatmentBleeding gumsSensitivity to hotLoose teethBroken teethBroken fillingsSensitivity to coldJaw pop/clickFood between teethGrinding teethSensitivity to sweetsJaw painSores in mouthGrowths in mouthSensitivity to bitingSwellingTooth achePain at nightOther
How often do you brush?
Floss?
Other concerns about your smile?
PATIENT MEDICAL HISTORY
Physician's Name
Date of last visit

MonthDayYear
Have you had any serious illnesses?

YesNo
If yes, describe
Have you had any surgeries/operations?

YesNo
If yes, describe
WOMEN
Pregnant?

YesNo
Due date

MonthDayYear
Nursing?

YesNo
Birth control pills?

YesNo
Have you ever taken any of the drugs referred to as "fen-phen"? These include Ionimin, Adipex, Fastin (phenteramine), Pondimin (fenfluramine) and/or Redux (dexfenfluramine)?

YesNo
Check if you have or have had any of the following:

AllergiesCough, persistentHepatitisSeizuresAnemiaCough up bloodHigh blood pressureScarlet feverArthritis, rheumatismDiabetesHIV/AIDSShortness of breathArtificial heart valveDiet, special/restrictedHigh cholesterolSinus problemsArtificial jointDrug/alcohol problemJaundiceSkin rashAsthmaEmphysemaKidney problemStent, cardiacBack problemsEpilepsyLatex sensitivityStomach/GI problemBlood disease/hemophiliaFainting/dizzinessLiver problemStrokeBlood transfusionGlaucomaLow blood pressureSwollen feet/anklesBruise easilyHay feverMigrainesThyroid problemCancerHeadachesMitral valve prolapseTIA/mini-strokeCanker sore/fever blisterHeart attackNeurological problemTobacco habitChemotherapyHeart diseaseOsteoporosisTonsillitisChest painHeart murmurPacemakerTuberculosisCirculatory problemsHeart pacemakerRadiation treatmentTumorCortisone shotsHeart problemsRheumatic feverUlcerBlood thinnersPrednisone/steroidsTake antibiotic before receiving dental treatment
Any other not listed above
List current medicines*
List allergies to medicines*
Signature Patient/Parent/Guardian

Clear
Date

MonthDayYear
Printed Name of above person
Relation to pt
Signature Mellanie Thompson, DDS

Clear
Date

MonthDayYear
Should be Empty:

HEALTH HISTORY

PATIENT DENTAL HISTORY

PATIENT MEDICAL HISTORY

WOMEN