Patient Health History Form- Madison Dentistry

Patient Health History Form
Patient Name Nickname Age Name of Physician/and their specialty Most recent physical examination Purpose What is your estimate of your general health? Excellent Good Fair Poor
Do You Have Or Have You Ever Had
1. Hospitalization For Illness Or Injury

YesNo
Reason for Hospitalization
If No, please type in "No"
2. An Allergic Or Bad Reaction To Any Of The Following:

YesNo
If YES, please select

aspirin, ibuprofen, acetaminophen, codeinepenicillinerythromycintetracyclinesulfalocal anestheticfluoridemetals (nickel, gold, silver, )latexnutsfruitOther
3. Heart Problems, Or Cardiac Stent Within The Last Six Months

YesNo
4. History Of Infective Endocarditis

YesNo
5. Artificial Heart Valve, Repaired Heart Defect (PFO)

YesNo
6. Pacemaker Or Implantable Defibrillator

YesNo
7. Orthopedic Or Soft Tissue Implant (E.G Joint Replacement, Breast Implant)

YesNo
8. Heart Murmur, Rheumatic Or Scarlet Feve

YesNo
9. High Or Low Blood Pressure

YesNo
10. A Stroke (Taking Blood Thinners)

YesNo
11. Anemia Or Other Blood Disorder

YesNo
12. Prolonged Bleeding Due To A Slight Cut (Or Inr > 3.5)

YesNo
13. Pneumonia, Emphysema, Shortness Of Breath, Sarcoidosis

YesNo
14. Chronic Ear Infections, Tuberculosis, Measles, Chicken Pox

YesNo
15. Breathing Problems (E.g. Asthma, Stuffy Nose, Sinus Congestion)

YesNo
16. Sleep Problems (E.g. Sleep Apnea, Snoring, Insomnia, Restless Sleep, Bedwetting)

YesNo
17. Kidney Disease

YesNo
18. Liver Disease Or Jaundice

YesNo
19. Vertigo (E.g. ”the Room Is Spinning”)

YesNo
20. Thyroid, Parathyroid Disease, Or Calcium Deficiency

YesNo
21. Hormone Deficiency Or Imbalance (E.g. Poly Cystic Ovarian Syndrome)

YesNo
22. High Cholesterol Or Taking Statin Drugs

YesNo
23. Diabetes

YesNo
24. Stomach Or Duodenal Ulcer

YesNo
25. Digestive Or Eating Disorders (E.g. Celiac Disease, Gastric Reflux, Bulimia, Anorexia)

YesNo
26. Osteoporosis/osteopenia Or Ever Taken Anti-resorptive Medications (E.g. Bisphosphonates)

YesNo
27. Arthritis Or Gout

YesNo
28. Autoimmune Disease (E.g. Rheumatoid Arthritis, Lupus, Scleroderma)

YesNo
29. Glaucoma

YesNo
30. Contact Lenses

YesNo
31. Head Or Neck Injuries

YesNo
32. Epilepsy, Convulsions (Seizures)

YesNo
33. Neurologic Disorders (E.g. Alzheimer’s Disease, Dementia, Prion Disease)

YesNo
34. Viral Infections And Cold Sores

YesNo
35. Any Lumps Or Swelling In The Mouth

YesNo
36. Hives, Skin Rash, Hay Fever

YesNo
37. STI/STD/HPV

YesNo
38. Hepatitis

YesNo
39. HIV/AIDS

YesNo
40. Tumor, Abnormal Growth

YesNo
41. Radiation Therapy

YesNo
42. Chemotherapy, Immunosuppressive Medication

YesNo
43. Emotional Difficulties

YesNo
44. Psychiatric Treatment Or Antidepressant Medication

YesNo
45. Concentration Problems or ADD/ADHD

YesNo
46. Alcohol/recreational Drug Use

YesNo
ARE YOU:
47. Presently Being Treated For Any Other Illness

YesNo
48. Aware Of A Change In Your Health In The Last 24 Hours (E.g., Fever, Chills, New Cough, Or Diarrhea)

YesNo
49. Taking Medication For Weight Management

YesNo
50. Taking Dietary Supplements, Vitamins, And/or Probiotics

YesNo
51. Often Exhausted Or Fatigued

YesNo
52. Experiencing Frequent Headaches Or Chronic Pain

YesNo
53. A Smoker, Smoked Previously Or Other (E.g. Smokeless Tobacco, Vaping, E-cigarettes, And Cannabis)

YesNo
54. Considered A Touchy/sensitive Person

YesNo
55. Often Unhappy Or Depressed

YesNo
56. Taking Birth Control Pills

YesNo
57. Currently Pregnant

YesNo
58. Diagnosed With A Prostate Disorder

YesNo
Describe any current medical treatment, impending surgery, genetic/development delay, or other treatment that may possibly affect your dental treatment. (i.e. Botox, Collagen Injections)
List all Medications, Supplements, Vitamins, and/or Probiotics taken within the last two years.
Drug
Purpose
Drug
Purpose
Please Advise Us In The Future Of Any Change In Your Medical History Or Any Medications You May Be Taking.
Patient’s Signature

Clear
Date

MonthDayYear
Doctor’s Signature

Clear
Date

MonthDayYear
Should be Empty:

Patient Health History Form

Do You Have Or Have You Ever Had

ARE YOU:

List all Medications, Supplements, Vitamins, and/or Probiotics taken within the last two years.

Please Advise Us In The Future Of Any Change In Your Medical History Or Any Medications You May Be Taking.