HEALTH HISTORY ASSESSMENT

HEALTH HISTORY ASSESSMENT
Patient Name
Date of Birth

MonthDayYear
Month / Day / Year
Have you had to have any of the pre-medication?

Pre-med-AmoxicillinPre-Med–ClindamycinOther
Do you have, or have you had any of the following Allergies?

Allergy - AmoxicillinAllergy – ErythromycinAllergy – NSAIDsAllergy – TetracyclineAllergy – AspirinAllergy – Hay FeverAllergy – IbuprofenAllergy – ClindamycinAllergy – PenicillinAllergy – CodeineAllergy – LatexAllergy – SulfaAllergy – metalsOther
Do you have, or have you had any of the following?

AnemiaAnxietyArthritisArtificial jointsAsthmaBlood diseaseCancerChemotherapyDiabetesDizzinessEpilepsyHigh cholesterolFaintingGERDGlaucomaHead injuriesHeart AttackHeart murmurHepatitisHerpesUlcersHIVIBSKidney diseaseLiver diseaseMental health condt.PacemakerRadiation treatmentRespiratory problemsRheumatic feverStomach problemsStroke / TIAThyroid problemsTransplantTuberculosisTumorsOther
Do you have, or have you had "Sleep problems"?

YesNo
Do you have, or have you had "Abnormal bleeding"?

YesNo
Do you have, or have you had "Snoring"?

YesNo
Do you have, or have you had "Joint replacement"? (e.g. total hips, pins, or implants)

YesNo
Do you have, or have you had "High blood pressure"?

YesNo
Do you have, or have you had "Infective Endocarditis"?

YesNo
Do you have, or have you had "Heart valve problem"?

YesNo
Do you have, or have you had "Taking heart medication"?

YesNo
During the past 12 months, have you taken any of the following?

Anticoagulants / Blood thinnersDigitalis or drugs for heart troubleNitroglycerinCortisone (steroids)Natural remediesFrequent or severe headachesTemporomandibular (jaw) disorder e.g. TMD or TMJSmoke or use chewing tobacco
Have you seen a medical doctor during the past two years?

YesNo
Name of Physician
What medications are you currently taking
Do you have any disease, condition, or problem not listed previously that you feel we should know about? If so, please describe:
Women

Taking contraceptives or hormonesPregnant
Signature of patient parent or guardian

Clear
Date

MonthDayYear
Month / Day / Year
Should be Empty: