Health History Form
Dr. Ryan Senft
Patient Name
*
First Name
Last Name
Patient Birthdate
*
.
Month
.
Day
Year
Patient Biologic Sex
*
Female
Male
Pregnant or Nursing
Pregnant
Nursing
Pregnant or Nursing
Check All That Apply
General health not good
Currently being treated by a physician for a medical condition
Been to the emergency department, been hospitalized, had surgery, or had a serious illness in the last two years
Taking prescription medications, nonprescription medications, or recreational drugs
Allergies
Tobacco use
Dry mouth
Shortness of breath at rest
High blood pressure
Congestive heart failure
Chest pain
Heart attack
Stroke
Prolonged bleeding
Sinus problems
Asthma
Persistent cough
Fainting
Gastroesophageal reflux disease (GERD)
Convulsions or epilepsy
Liver disease
Kidney disease
Diabetes
Cancer
Radiation therapy
Depression
General anxiety
Dental anxiety
Oral herpes
Canker sores (non-herpes)
Tuberculosis
HIV/AIDs
Sensitivity to epinephrine
CPAP
Oral sleep apnea device
Dental retainers
Dental nightguard
Complications associated with a joint replacement surgery
History of (a) prosthetic cardiac valves, including transcatheter-implanted prostheses and homografts; (b) prosthetic material used for cardiac valve repair, such as annuloplasty rings and chords; (c) infective endocarditis; (d) cardiac transplant with valve regurgitation due to a structurally abnormal valve; (e) congenital unrepaired cyanotic congenital heart disease, including palliative shunts and conduits; or (f) any repaired congenital heart defect with residual shunts or valvular regurgitation at the site of or adjacent to the site of a prosthetic patch or a prosthetic device
Use of antiresorptive or antiangiogenic medications, sometimes taken for osteoporosis or cancer; examples include alendronate (Fosamax), denosumab (Prolia, Xgeva), bevacizumab (Avasatin), sunitinib (Sutent), zoledronic acid (Zometa, Reclast), palmidronate (Aredia), ibandronate (Boniva), risedronate (Actonel), etidronate, (Didronel), and tiludronate (Skelid)
Other
Check All That Apply
Explain Your General Health Not Being Good
Explain Your Currently Being Treated by a Physician for a Medical Condition
Explain Your Emergency Department Visits, Hospitalizations, Surgeries, or Serious Illnesses in the Last Two Years
List Your Prescription Medications, Nonprescription Medications, and Recreational Drugs
List Your Allergies
Emergency Contact
*
First Name
Last Name
Emergency Contact Phone Number
*
Format: 000.000.0000.
Questions Asked
Pregnant Nursing General health not good Currently being treated by a physician for a medical condition Been to the emergency department, been hospitalized, had surgery, or had a serious illness in the last two years Taking prescription medications, nonprescription medications, or recreational drugs Allergies Tobacco use Dry mouth Shortness of breath at rest High blood pressure Congestive heart failure Chest pain Heart attack Stroke Prolonged bleeding Sinus problems Asthma Persistent cough Fainting Gastroesophageal reflux disease (GERD) Convulsions or epilepsy Liver disease Kidney disease Diabetes Cancer Radiation therapy Depression General anxiety Dental anxiety Oral herpes Canker sores (non-herpes) Tuberculosis HIV/AIDs Sensitivity to epinephrine CPAP Oral sleep apnea device Dental retainers Dental nightguard Complications associated with a joint replacement surgery History of (a) prosthetic cardiac valves, including transcatheter-implanted prostheses and homografts; (b) prosthetic material used for cardiac valve repair, such as annuloplasty rings and chords; (c) infective endocarditis; (d) cardiac transplant with valve regurgitation due to a structurally abnormal valve; (e) congenital unrepaired cyanotic congenital heart disease, including palliative shunts and conduits; or (f) any repaired congenital heart defect with residual shunts or valvular regurgitation at the site of or adjacent to the site of a prosthetic patch or a prosthetic device Use of antiresorptive or antiangiogenic medications, sometimes taken for osteoporosis or cancer; examples include alendronate (Fosamax), denosumab (Prolia, Xgeva), bevacizumab (Avasatin), sunitinib (Sutent), zoledronic acid (Zometa, Reclast), palmidronate (Aredia), ibandronate (Boniva), risedronate (Actonel), etidronate, (Didronel), and tiludronate (Skelid)
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