Degen DDS - Health History

Patient Name*

First NameLast Name

Patient Date of Birth*

MonthDayYear

Is this your FIRST TIME visiting our office?

YesNo

Has it been LONGER THAN 12 months since your LAST VISIT to our office?

YesNo

If you have visited our office within the past 12 months, have there been any changes in your health?

YesNo

Patient Height

Patient Weight

Patient Gender*

MaleFemale

Physician (Primary Care)

Physician Phone #

Pharmacy Name

Pharmacy Phone #

Medications*

	YES	NO	If OTHER, Please List
Aspirin, Motrin
OTHER anti-inflammatory
Coumadin Plavix, Lovenox, Eliquis, Xarelto
OTHER blood thinners
Vitamine E, Ginkgo Biloba, Ginseng, Garlic Pills
Fosamax (alendronate), Actonel (Risedronate), Zometa (Zoledronate), Prolia (Denosumab), Xgeva (Denosumab), Boniva (Ibandronate)/Reclast (Zoledronic Acid)

Please list all additional medications with dosages you are currently taking.

Are you in good health?

YesNo

Has there been any change in your health?

YesNo

Have you experienced any serious illness, operation, hospitalization within the last 5 years?

YesNo

If yes, please explain:

Health History*

	Yes	No
Damaged/Artificial Heart Valves, Heart Murmurs
Rheumatic Heart Disease
Heart Trouble/Heart Attack
High blood pressure, stroke arteriosclerosis
Chest pain upon exertion
Shortness of breath
Ankles swelling
Seasonal Allergies
Sinus Troubles
Asthma/Hay Fever
Fainting Spell or Seizure
Diabetes
Hepatitis, Jaundice or Liver Disease
Thyroid problem
Respiratory problems, emphysema, bronchitis, etc
Arthritis or painful, swollen joints, jaw joint (TMJ)
Stomach Ulcer or hyperacidity
Kidney Trouble
Tuberculosis
Persistent cough or phlegm that produces blood
Low blood pressure
Epilepsy or any other neurological disorder
Cancer
Skin disease
Mental illness/Psychiatric Disorder
Abnormal Bleeding
Any disease/drug/transplant operation that depresses your immune system
Blood transfusion
Blood disorder such as anemia
Treatment for a tumor or a growth
Do you smoke/use other tobacco products?
Do you consume alcoholic beverages?
Radiation therapy to your head or neck
Eye surgery within the past year?
Are you wearing contact lenses?
Strong gag reflex?

If you selected "yes" for any of the previous health conditions, please explain.

Do you have any other heart condition?

YesNo

If yes, please explain:

Have you had any serious trouble associated with previous dental treatment?

YesNo

If yes, please explain:

Have you or a family member ever had an adverse reaction to General Anesthesia?

YesNo

If yes, please explain:

Have you had any dental work in the past year?

YesNo

If yes, please explain:

Allergies*

	Yes	No
Local anesthetic (numbing injection)
Sulfa drugs
Penicillin or antibiotics
Aspirin
Codeine
Barbiturates or sleeping pills
Iodine
Latex
Eggs/Egg Protein

If you selected "yes" on any of the above allergies, please list the name of the medication and describe your reaction:

Do you have any other allergies?

YesNo

If yes, please list:

WOMEN ONLY

	Yes	No
Are you pregnant?
Do you have problems associated with your menstrual period?
Are you nursing?
Are you taking birth control pills?

Taking any unprescribed or illegal drugs may seriously interfere with the medications used in anesthesia and may ultimately lead to death. Please advise the doctor if you have used any such drugs in the past, especially within the past 48 hours.

I certify that i have read and understand the above. I acknowledge that any questions, if any the inquires set forth above have been answered to my satisfaction. I will not hold my Oral and Maxillofacial Surgeon or any member of the staff responsible for any errors or omissions that I may have made in the completion of this form.

Signature of Patient or Legal Guardian*

Date*

Date

------------------------ for office use only ------------------------

DOCTOR'S SIGNATURE:

Mark Degen, DDS, Signature

________________________________________

Reviewed by: Mark Degen, DDS, MD

Comments on patient interview concerning medical history:

__________________________________________________________________

Today's Date

Thank you for choosing our office.