Brampton Dental Arts - Adult Health and Dental History Form

Health History

Patient Name*

First NameLast Name

Gender*

Date:*

Medical Alert

Condition:

Premedication:

Have you visited a physician for a medication condition in the past two years?

YesNo

If yes, please explain

Physician:

Phone:

Area CodePhone Number

When was your last visit to a Physician?

Last complete physical examination?

Are you presently taking any PRESCRIPTION or NON-PRESCRIPTION drugs? Or have you recently taken any?

YesNo

If yes, please list:

Have you been hospitalized in the past two years?

YesNo

Describe

Have you ever reacted adversely to any of the following?

Antibiotics– Penicillin.*

YesNo

Sulfonamide*

YesNo

Other Antibiotics*

YesNo

Describe*

Asprin*

YesNo

Barbiturates (sleeping pills)*

YesNo

Codeine*

YesNo

Darvon*

YesNo

Local Anesthetic (freezing)*

YesNo

Nitrous oxide*

YesNo

Any other medication*

YesNo

Please list*

Have you ever been advised against taking any specific type of medication?*

YesNo

Describe*

Do you have any of the following?

Asthma*

YesNo

Hay Fever*

YesNo

Food Allergies*

YesNo

Metal or Latex Allergies*

YesNo

Skin Rashes*

YesNo

Hives*

YesNo

Any other allergic condition*

YesNo

Describe*

Has any family member had diabetes?*

YesNo

Describe*

Do you bleed EXCESSIVELY from a cut or injury, or bruise easily?*

YesNo

Describe*

Do your ankles, feet or hands swell?*

YesNo

Describe*

Has your weight, appetite or energy level changed dramatically recently?*

YesNo

Describe*

Do you experience shortness of breath or chest pain when talking or climbing stairs?*

YesNo

Describe*

Do you follow a special diet?*

YesNo

Describe*

Have you recently tested HIV positive?*

YesNo

Describe*

Do you have FREQUENT SEVERE headaches, earaches, ear/throat infections?*

YesNo

Describe*

Have you ever had any injury or surgery to your face or jaws?*

YesNo

Describe*

Do you wear eyeglasses or contact lenses?*

YesNo

Describe*

Do you have any hearing difficulties?*

YesNo

Describe

Do you smoke or use any other forms of tobacco?*

YesNo

Are you wearing the transdermal nicotine patch?*

YesNo

Describe

Are you alcohol and/or drug dependent?

YesNo

Have you received treatment?

YesN0

Describe

Indicate Which of the Following You Presently Have or Ever Had

A.I.D.S*

YesNo

Arthritis / Rheumatism*

YesNo

Blood disorders*

YesNo

Circulation problems*

YesNo

Diabetes

YesNo

Fainting or dizzy spells*

YesNo

Head / neck injuries*

YesNo

Heart pacemaker*

YesNo

Hepatitis A*

YesNo

Heart pacemaker

YesNo

Herpes*

YesNo

Hyper (Hypo) Glycaemia*

YesNo

Kidney disease*

YesNo

Malignant hyperthermia*

YesNo

Organ transplant/ medical transplant*

YesNo

Rheumatic / Scarlet fever*

YesNo

Stomach / intestinal problems*

YesNo

Tuberculosis*

YesNo

Anemia*

YesNo

Artificial heart-valve*

YesNo

Bronchitis*

YesNo

Congenial heart lesions*

YesNo

Emphysema*

YesNo

Glandular disorders*

YesNo

Heart disease or attack*

YesNo

Heart rhythm disorder*

YesNo

Hepatitis B*

YesNo

High/Low blood pressure*

YesNo

Hypertension*

YesNo

Liver disease*

YesNo

Mental/nervous disorder*

YesNo

Psychiatric treatment*

YesNo

Sickle cell disease*

YesNo

Stroke*

YesNo

Ulcers*

YesNo

Angina pectoris*

YesNo

Artificial joints (hips, knee)*

YesNo

Cancer*

YesNo

Cortisone / steroid*

YesNo

Epilepsy or seizures*

YesNo

Glaucoma*

YesNo

Heart murmur*

YesNo

Hepatitis C*

YesNo

Hodgkin’s disease*

YesNo

Jaundice*

YesNo

Lung disease*

YesNo

Mitral valve prolapse*

YesNo

Radiation treatment/ chemotherapy*

YesNo

Sinus trouble*

YesNo

Thyroid disease*

YesNo

Venereal disease*

YesNo

Other

Has the CHILD PATIENT recently had any of the following

Measles*

YesNo