crestviewfamilydentaldds.com - Confidential Health History

Patient Name *

First Name Last Name

Date of Birth *

Month Day Year

Is your general health good?

Yes No

If NO, Explain

Has there been a change in your health within the last year?

Yes No

If YES, Explain

Have you gone to the hospital or emergency room or had a serious illness in the last three years?

Yes No

If YES, Explain

Are you being treated by a physician now?

Yes No

If YES, Explain

Date of last medical exam?

Date

Reason for exam

Have you had problems with prior dental treatment?

Yes No

If YES, Explain

Date of last medical exam?

Date

Name of last treating dentist

Are you in pain now?

Yes No

If YES, Explain

Chest Pain *

Yes No

(Angina) Fainting *

Yes No

Spells Recent Significant Weight Loss *

Yes No

Fever *

Yes No

Night Sweats *

Yes No

Persistent Cough *

Yes No

Coughing up Blood *

Yes No

Bleeding Problems *

Yes No

Blood in Urine *

Yes No

Blood in Stools *

Yes No

Diarrhea or Constipation *

Yes No

Frequent Urination *

Yes No

Difficulty Urinating *

Yes No

Ringing in Ears *

Yes No

Headaches *

Yes No

Dizziness *

Yes No

Blurred Vision *

Yes No

Bruise Easily *

Yes No

Vomiting *

Yes No

Frequent Jaundice *

Yes No

Dry Mouth *

Yes No

Excessive Thirst *

Yes No

Difficulty Swallowing *

Yes No

Swollen Ankles *

Yes No

Joint Pain or Stiffness *

Yes No

Shortness of Breath *

Yes No

Sinus Problems *

Yes No

Heart Disease *

Yes No

Family History of Heart Disease *

Yes No

Heart Attack *

Yes No

Artificial Joint *

Yes No

Stomach Problems or Ulcers *

Yes No

Heart Defects *

Yes No

Heart Murmurs *

Yes No

Rheumatic Fever *

Yes No

Skin Disease *

Yes No

Hardening of Arteries *

Yes No

High Blood Pressure *

Yes No

Seizures *

Yes No

Cosmetic Surgery *

Yes No

AIDS / HIV *

Yes No

Surgeries *

Yes No

Hospitalization *

Yes No

Diabetes *

Yes No

Family History of Diabetes *

Yes No

Tumors or Cancer *

Yes No

Chemotherapy *

Yes No

Radiation *

Yes No

Arthritis, Rheumatism *

Yes No

Emphysema or other Lung *

Yes No

Kidney or Bladder Disease *

Yes No

Stroke *

Yes No

Eating Disorders *

Yes No

Psychiatric Care *

Yes No

Osteoporosis *

Yes No

Thyroid Disease *

Yes No

Asthma *

Yes No

Hepatitis *

Yes No

Sexual Transmitted *

Yes No

Herpes *

Yes No

Canker or Cold Sores *

Yes No

Anemia *

Yes No

Liver Disease *

Yes No

Eye Disease *

Yes No

Transplants *

Yes No

Tuberculosis *

Yes No

Aspirin *

Yes No

Penicillin or other Antibiotics *

Yes No

Nitrous Oxide *

Yes No

Valium or other *

Yes No

Sedatives Latex *

Yes No

Local Anesthetic *

Yes No

Codeine or other *

Yes No

Narcotics Food *

Yes No

Metal *

Yes No

Other *

Yes No

If "Other" Please Explain? *

Recreational Drugs *

Yes No

Over-the-Counter Medicines *

Yes No

Weight Loss Medications *

Yes No

Anti-Depressants *

Yes No

Tobacco in any form *

Yes No

Alcohol *

Yes No

Bisphosphonate (Fosamax) *

Yes No

Herbal Supplements *

Yes No

Antibiotics *

Yes No

Supplement *

Yes No

Aspirin *

Yes No

Please List All Prescription Medications

Are you or could you be pregnant? *

Yes No

If YES, what month? *

Are you Nursing? *

Yes No

Are you taking birth control pills? *

Yes No

Do you have or have you had any other diseases or medical problems NOT listed on this form? *

Yes No

If YES, Explain *

Have you ever been pre-medicated for dental treatment? *

Yes No

If YES, Why? *

Have you ever taken Fen-Phen? *

Yes No

If YES, When? *

Is there any issue or condition that you would like to discuss with the dentist in private? *

Yes No

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

Physician’s Name

Phone Number

Please enter a valid phone number.

Name *

Relationship *

Phone Number *

Please enter a valid phone number.

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.

Signature of Patient (Parent/Guardian) *

Clear

Name *

First Name Last Name

Date *

Date

Confidential Health History

SELECT APPROPRIATE ANSWER

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

ALL PATIENTS

Whom would you like us to contact in case of an emergency?