thedentalmasters.org - Belmont Health History Form

Belmont Health History Form
Patient Name*
Birth Date*

MonthDayYear
Date
Cell #:*
Please enter a valid phone number.
Email:*
example@example.com
Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may hav, or medication that you may be taking.
Are you under the physician's care now?*

YesNo
Physician’s Name:
Date of Last Visit:

MonthDayYear
Date
If yes*
Have you ever been hospitalized or had a major operation?*

YesNo
If yes*
Have you ever had a serious head or neck injury?*

YesNo
If yes*
Are you taking any medications, pills, or drugs?*

YesNo
If yes*
Have you ever taken fosamax, Boniva, Actonel or any other medications containing bisphosphonates?*

YesNo
If yes*
Do you use tobacco?*

YesNo
Do you use controlled substances?*

YesNo
If yes*
Women: Are you...

PregnantTrying to get pregnantNursingTaking oral contraceptives
Are you allergic to any of following?

AspirinMentalSeasonalLatexPenicillinCodeineSulfa DrugsOther
Do you have, or have you had, any of the following?

AIDS/HIV ⁪Cortisone Treatments ⁪Hemophilia ⁪Radiation Treatments⁪Alzheimer’s Disease ⁪Diabetes ⁪Hepatitis A ⁪Recent WeightlossAnaphylaxis ⁪Drug Addiction ⁪Hepatitis B or C ⁪Renal Dialysis⁪Anemia ⁪Easily Winded ⁪Herpes ⁪Rheumatic Fever⁪Angina ⁪Emphysema ⁪High Blood Pressure ⁪Rheumatism⁪Arthritis, Rheumatism/Gout ⁪Epilepsy or Seizures ⁪High Cholesterol ⁪Scarlet FeverArtificial Heart Valve(s) ⁪Excessive Bleeding ⁪Hives or Rash ⁪ShinglesArtificial Joints ⁪Excessive Thirst ⁪Hypoglycemia ⁪Sickle Cell Disease⁪Asthma ⁪Fainting/Dizziness ⁪Irregular Heartbeat ⁪Sinus Trouble⁪Blood Disease ⁪Frequent Cough ⁪Kidney Problems ⁪Spina Bifida⁪Blood Transfusion ⁪Frequent Diarrhea ⁪Leukemia ⁪Stomach/Intestinal Disease⁪Breathing Problems ⁪Frequent Headaches ⁪Liver Disease ⁪Stroke⁪Bruise Easily ⁪Herpes ⁪Low Blood Pressure ⁪Swelling of Limbs⁪Cancer ⁪Glaucoma ⁪Lung Disease ⁪Thyroid Disease⁪Chemotherapy ⁪Hay Fever ⁪Mitral Valve Prolapse ⁪Tonsillitis⁪Chest pains ⁪Heart Attach/Failure ⁪Osteoporosis ⁪Tuberculosis⁪Cold sores / Fever Blisters ⁪Heart Murmur ⁪Pain in Jaw Joints ⁪Tumors or Growths⁪Congenital Heart Disorder ⁪Heart Pacemaker ⁪Parathyroid Disease ⁪Ulcers⁪Convulsions ⁪Heart Trouble/Disease ⁪Psychiatric Care ⁪Venereal Disease⁪Yellow Jaundice
Have you ever had serious illness not listed above?*

YesNo
If yes*
Comments
To the best of my knowledge, the questions on this form have been accurately answered. I understand providing incorrect information can be dangerous to my (or patient's) health.It is my responsibility to inform the dental office of any changes in medical status.
Signature of Patient, Parent or Guardian::*

Clear
Date:*

MonthDayYear
Date
Should be Empty: