health_history_form

Patient Name
Date of Birth

MonthDayYear
Date
1. Is your general health good?

YesNo
If No, Explain:
2. Has there been a change in your health within the last year?

YesNo
If YES, explain:
3. Have you gone to the hospital or emergency room or had a serious illness in the last three years?

YesNo
If YES, explain
4. Are you being treated by a physician now?

YesNo
If YES, explain
Date of last medical exam?

MonthDayYear
Date
Reason for exam
5. Have you had problems with prior dental treatment?

YesNo
If YES, explain
Date of last dental exam

MonthDayYear
Date
Name of last treating dentist
6. Are you in pain now?

YesNo
If YES, explain
HAVE YOU EVER EXPERIENCED ANY OF THE FOLLOWING?
Chest Pain (angina)

YesNo
Blood in stools

YesNo
Frequest Vomitting

YesNo
Fainting spells

YesNo
Diarrhea or constipation

YesNo
Jaundice

YesNo
Recent significant weight loss

YesNo
Frequent Urination

YesNo
Dry mouth

YesNo
Fever

YesNo
Difficulty urinating

YesNo
Excessive Thirst

YesNo
Night Sweats

YesNo
Ringing in ears

YesNo
Difficulty swallowing

YesNo
Persistent cough

YesNo
Headache

YesNo
Swollen ankles

YesNo
Coughing up blood

YesNo
Dizziness

YesNo
Joint pain or stiffness

YesNo
Bleeding problems

YesNo
Blurred vision

YesNo
Shortness of breath

YesNo
Blood in urine

YesNo
Bruise easily

YesNo
Sinus problems

YesNo
Others
HAVE YOU EVER HAD OR DO YOU HAVE ANY OF THE FOLLOWING?
Heart disease

YesNo
AIDS/HIV

YesNo
Psychiatric care

YesNo
Family history of heart disease

YesNo
Surgeries

YesNo
Osteoporosis

YesNo
Heart attack

YesNo
Hospitalization

YesNo
Thyroid disease

YesNo
Artificial joint

YesNo
Diabetes

YesNo
Asthma

YesNo
Stomach problems or ulcers

YesNo
Family history of diabetes

YesNo
Hepatitis

YesNo
Heart defects

YesNo
Tumors or cancer

YesNo
Sexual transmitted disease

YesNo
Heart murmurs

YesNo
Chemotherapy

YesNo
Herpes

YesNo
Rheumatic fever

YesNo
Radiation

YesNo
Canker or cold sores

YesNo
Skin disease

YesNo
Athritis, theumatism

YesNo
Anemia

YesNo
Hardening of arteries

YesNo
Emphysema or other lung disease

YesNo
Liver disease

YesNo
High blood pressure

YesNo
Kidney or bladder disease

YesNo
Eye disease

YesNo
Seizures

YesNo
Stroke

YesNo
Transplants

YesNo
Cosmetic surgery

YesNo
Eating disorders

YesNo
Tuberculosis

YesNo
Others
ARE YOU ALLERGIC TO OR HAVE YOU HAD A REACTION TO ANY OF THE FOLLOWING?
Aspirin

YesNo
Valium or other sedatives

YesNo
Codeine or other narcotics

YesNo
Penicillin or other antibiotics

YesNo
Latex

YesNo
Food

YesNo
Nitrous oxide

YesNo
Local anesthetic

YesNo
Metal

YesNo
Others
ARE YOU TAKING OR HAVE YOU TAKEN ANY OF THE FOLLOWING IN THE LAST THREE MONTHS?
Recreational drugs

YesNo
Tobacco in any form

YesNo
Antibiotics

YesNo
Over the counter medicines

YesNo
Alcohol

YesNo
Supplements

YesNo
Weight loss medications

YesNo
Bisphosphonate(Fosamax)

YesNo
Aspirin

YesNo
Antidepressant

YesNo
Herbal supplements

YesNo
Please list all prescription medications
WOMEN ONLY(Please check Yes or No for each)
Are you or could you be pregnant?

YesNo
Are you or could you be pregnant? If YES, what month?
Are you nursing?

YesNo
Are you taking birth control pills?

YesNo
All patients (Please check Yes or No for each)
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?

YesNo
If YES, when
Is there any issue or condition that you would like to discuss with the dentist in private?

YesNo
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.

I authorize the dentist to contact my physician.
Patient’s Signature

Clear
Date

MonthDayYear
Date
Physician’s Name
Phone Number
Whom would you like us to contact in case of an emergency?
Name
Relationship
Phone Number
Signature of Patient (Parent or Guardian)
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.

Clear
Date

MonthDayYear
Date
MEDICAL UPDATES

I have reviewed my Health History and confirm that it accurately states past and present conditions.

	DATE	PATIENT SIGNATURE	CHANGES TO HEALTH HISTORY	DENTIST INITIALS

Should be Empty:

HAVE YOU EVER EXPERIENCED ANY OF THE FOLLOWING?

HAVE YOU EVER HAD OR DO YOU HAVE ANY OF THE FOLLOWING?

ARE YOU ALLERGIC TO OR HAVE YOU HAD A REACTION TO ANY OF THE FOLLOWING?

ARE YOU TAKING OR HAVE YOU TAKEN ANY OF THE FOLLOWING IN THE LAST THREE MONTHS?

WOMEN ONLY(Please check Yes or No for each)

All patients (Please check Yes or No for each)

MEDICAL UPDATES