Adult Health History - Hislop-Lepak Family Dental

Patient Dental & Medical Health History Information
To our patients: Please know that we may ask follow-up questions to make sure we have all of the information we need in order to treat you.
Today’s Date

MonthDayYear
Date
PATIENT INFORMATION
Name

First NameMiddle NameLast Name
Home Phone
Cell Phone
Work Phone
Email Address
example@example.com
Address

Mailing Address

Street Address Line 2

CityState / Province

Zip
Date of Birth:
MM / DD / YYYY
Gender
Occupation
Emergency Contact:
Name
Relationship
Phone
If you are completing this form for another person, what is your name and relationship to that person? Name
Relationship
If executing this form as the patient’s personal representative, I represent and warrant that I have full legal right and authority to consent to the performance of any procedure(s) on this patient. If for any reason I no longer have such legal right and authority, I will immediately notify the practice in writing.

	Yes	No	?
Aspirin
Barbiturates, sedatives, or sleeping pills
Codeine or other narcotics
Hay feaver/seasonal allergies
Iodine
Latex (rubber)
Local anesthetics
Metals
Penicillin or other antibiotics
Sulfa drugs such as sulfamethoxazole-trimethoprim (Septra, Bactrim), erythromycin-sulfisoxazole, sulfasala-zine (Azulfidine), erythromycin- sulfisoxazole (Eryzole, Pediazole) glyburide (Diabeta, Glynase PresTabs), dapsone, sumatriptan (Imitrex), celecoxib (Celebrex), hydrochlorothiazide (Microzide) and furosemide (Lasix)
Other

	Yes	No	?
Are you in good physical health?
Are you currently being seen or treated by a physician?
Has a physician or previous dentist recommended that you take antibiotics before having dental work done?
Have you had a serious illness, operation or been hospitalized in the past 5 years?
Have you had any type (either total or partial) of joint replacement surgery (such as for a hip, knee, shoulder, elbow, finger, etc.)?
Have you had a heart valve replacement or heart surgery?
Have you had an organ or bone marrow/stem cell transplant?
Have you traveled internationally within the last 30 days?
Have you had a fever (100.4 degrees F or above) in the last 72 hours?

	Yes	No	?
Pacemaker/implanted defibrillator
Artificial (prosthetic) heart valve
Previous infective endocarditis
Congenital heart disease (CHD)
Unrepaired, cyanotic CHD
Repaired CHD (completely) in last 6 months
Repaired CHD with residual defects
Arteriosclerosis
Coronary artery disease
Congestive heart failure
Damaged heart valves
Heart attack
Heart murmur/rhythm disorder
Rheumatic heart disease
Stroke

Patient Dental & Medical Health History Information

	Yes	No	?
Anxiety
Depression
Epilepsy
Mental health disorders
Neurological disorders
Post-traumatic stress disorder
Traumatic brain injury or concussion

	Yes	No	?
Gastrointestinal disease
G.E. reflux/persistent heartburn (GERD)
Stomach ulcers

	Yes	No	?
Arthritis
Chronic pain
Diabetes (type I or II)
Eating disorder
Frequent infections
Hepatitis, jaundice, or liver disease
Immune deficiency
Kidney problems
Malnutrition
Osteoporosis
Rheumatoid arthritis
Sexually transmitted infection (STI)
Thyroid problems

	Yes	No	?
had pain or tightness in the chest?
coughed up blood or had a cough that lasted longer than 3 weeks?
been exposed to anyone with tuberculosis?
had a rapid or irregular heart beat?
found it hard to catch your breath?
had a high fever (greater than 101.5 ̊F) for no reason?
noticed a change in your vision?
fainted for no reason?
experienced vomiting, diarrhea, chills, night sweats or bleeding?
had migraines or severe headaches?

	Yes	No	?
AIDS or HIV Infection
Depression