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 Fever/SeasonalAllergy – IbuprofenAllergy – ClindamycinAllergy – PenicillinAllergy – CodeineAllergy – LatexAllergy – SulfaAllergy – metalsOther
Do you have, or have you had any of the following?

High Blood PressureHigh CholesterolDiabetesAnemiaAnxietyArthritisAsthmaBlood diseaseCancerChemotherapyDizzinessEpilepsyFaintingGERDGlaucomaHead injuriesHeart murmurHepatitisHerpesUlcersHIVIBSKidney diseaseLiver diseaseMental health condt.PacemakerRadiation treatmentRespiratory problemsRheumatic feverStomach problemsThyroid problemsTransplantTuberculosisTumorsOther
Have you had "Infective Endocarditis"?*

YesNo
Have you had "Joint replacement"? (e.g. total hips, knee, or shoulder)*

YesNo
Have you had "Congenital Heart Disease"?*

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

YesNo
Have you had a "Heart Attack"?*

YesNo
Have you had a "Stroke/TIA"?*

YesNo
Do you have, or have you had "Sleep problems/Snoring"?*

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

YesNo

During the past 12 months, have you had any of the following*

	Yes	No
Anticoagulants / Blood Thinners
Digitalis or drugs for heart trouble
Nitroglycerin
Cortisone (steroids)

	Yes	No
Natural remedies
Frequent or severe headaches
Temporomandibular (jaw) disorder eg TMJ or TMD
Smoke 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 hormones?*

YesNon/a
Women - Pregnant or possibly pregnant?*

YesNon/a
Signature of patient parent or guardian*

Clear
Date*

MonthDayYear
Month / Day / Year
Should be Empty: