• HEALTH HISTORY

    Correct answers to the following questions will allow us to treat you on a more individual basis, providing the care appropriate for your particular needs.
  • Birthdate*
     - -

  • Please answer each question below. Check yes or no. 

  • Are you in good health now?
  • Are you now under the care of a physician?*
  • Have you ever been hospitalized or had a serious illness?*
  • Have you ever had excessive bleeding following an extraction?*
  • Do cuts take a long time to heal?*

  • Do you have or have you ever had any of the following? Please indicate yes or no below.

  • GENERAL

  • Tire easily, weakness*

  • EYES

  • Glaucoma*

  • NOSE

  • Frequent nose bleeds*
  • Sinus Problems*

  • NERVOUS SYSTEM

  • Stroke*
  • Headaches*
  • Convulsions/epilepsy*

  • HEART/BLOOD VESSELS

  • Heart Murmur*
  • Chest pain/discomfort*
  • Heart attack/trouble*
  • Shortness of breath*
  • High Blood Pressure*
  • Congenital heart disease*
  • Mitral Valve Prolapse*
  • Artificial heart valve*
  • Heart Surgery*
  • Pacemaker*
  • Rheumatic Fever*

  • BONES/MUSCLES

  • Arthritis/rheumatism*
  • Artificial joints/limbs*

  • DIGESTIVE SYSTEM

  • Hepatitis*
  • Jaundice*
  • Ulcers*

  • URINARY

  • Kidney Disease*
  • Venereal Disease*

  • BLOOD

  • Bruise easily*
  • Anemia*
  • Blood transfusion*

  • RESPIRATORY

  • Emphysema*
  • Asthma/hay fever*
  • Tuberculosis*

  • ENDOCRINE

  • Diabetes*
  • Family history of diabetes*
  • Thyroid condition/goiter*

  • OTHER

  • Radiation therapy*
  • Chemotherapy*
  • Tumors or growths*
  • Cancer*
  • HIV+/AIDS*

  • Are you ALLERGIC or have ever experienced any reaction to the following?

  • Local anesthetics (novocaine, etc)*
  • Barbiturates/sedative/sleeping pills*
  • Penicillin/other antibiotics*
  • Aspirin or codeine*
  • Sulfa drugs*
  • Does dental treatment make you nervous?
  • Do you need to premedicate with an antibiotic prior to dental treatment?*

  • Are you taking any of the following?

  • Antibiotics/sulfa drugs*
  • Blood thinners*
  • Blood pressure medication*
  • Thyroid medication*
  • Cortisone/steroids*
  • Antihistamines/allergy drugs/cold remedies*
  • Birth control pills*
  • Insulin/other diabetes drugs*
  • Recreational drugs*
  • Heart medications*
  • Nitroglycerin*
  • Aspirin*
  • Other medication*
  • Have you ever had treatment for breast cancer or have you been treated with chemotherapeutic drugs and intravenous Bisphonates? (Intravenous Bisphosphonates therapy, or bone-sparing drugs are commonly used on the treatment of osteoporosis and metastatic bone cancer to help decrease associated pain and fractures following treatment for breast cancer.)*

  • To the best of my knowledge, all of the preceding answers are true and correct. If I ever have any change in my health or change in my medication, I will inform the dentist at the next appointment.

  • Today's Date*
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