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

Other
3. Heart Problems, Or Cardiac Stent Within The Last Six Months
4. History Of Infective Endocarditis
5. Artificial Heart Valve, Repaired Heart Defect (PFO)
6. Pacemaker Or Implantable Defibrillator
7. Orthopedic Or Soft Tissue Implant (E.G Joint Replacement, Breast Implant)
8. Heart Murmur, Rheumatic Or Scarlet Feve
9. High Or Low Blood Pressure
10. A Stroke (Taking Blood Thinners)
11. Anemia Or Other Blood Disorder
12. Prolonged Bleeding Due To A Slight Cut (Or Inr > 3.5)
13. Pneumonia, Emphysema, Shortness Of Breath, Sarcoidosis
14. Chronic Ear Infections, Tuberculosis, Measles, Chicken Pox
15. Breathing Problems (E.g. Asthma, Stuffy Nose, Sinus Congestion)
16. Sleep Problems (E.g. Sleep Apnea, Snoring, Insomnia, Restless Sleep, Bedwetting)
17. Kidney Disease
18. Liver Disease Or Jaundice
19. Vertigo (E.g. ”the Room Is Spinning”)
20. Thyroid, Parathyroid Disease, Or Calcium Deficiency
21. Hormone Deficiency Or Imbalance (E.g. Poly Cystic Ovarian Syndrome)
22. High Cholesterol Or Taking Statin Drugs
23. Diabetes
24. Stomach Or Duodenal Ulcer
25. Digestive Or Eating Disorders (E.g. Celiac Disease, Gastric Reflux, Bulimia, Anorexia)
26. Osteoporosis/osteopenia Or Ever Taken Anti-resorptive Medications (E.g. Bisphosphonates)
27. Arthritis Or Gout
28. Autoimmune Disease (E.g. Rheumatoid Arthritis, Lupus, Scleroderma)
29. Glaucoma
30. Contact Lenses
31. Head Or Neck Injuries
32. Epilepsy, Convulsions (Seizures)
33. Neurologic Disorders (E.g. Alzheimer’s Disease, Dementia, Prion Disease)
34. Viral Infections And Cold Sores
35. Any Lumps Or Swelling In The Mouth
36. Hives, Skin Rash, Hay Fever
37. STI/STD/HPV
38. Hepatitis
39. HIV/AIDS
40. Tumor, Abnormal Growth
41. Radiation Therapy
42. Chemotherapy, Immunosuppressive Medication
43. Emotional Difficulties
44. Psychiatric Treatment Or Antidepressant Medication
45. Concentration Problems or ADD/ADHD
46. Alcohol/recreational Drug Use
ARE YOU:
47. Presently Being Treated For Any Other Illness
48. Aware Of A Change In Your Health In The Last 24 Hours (E.g., Fever, Chills, New Cough, Or Diarrhea)
49. Taking Medication For Weight Management
50. Taking Dietary Supplements, Vitamins, And/or Probiotics
51. Often Exhausted Or Fatigued
52. Experiencing Frequent Headaches Or Chronic Pain
53. A Smoker, Smoked Previously Or Other (E.g. Smokeless Tobacco, Vaping, E-cigarettes, And Cannabis)
54. Considered A Touchy/sensitive Person
55. Often Unhappy Or Depressed
56. Taking Birth Control Pills
57. Currently Pregnant
58. Diagnosed With A Prostate Disorder
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
Date

MonthDayYear
Doctor’s Signature
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.