St. Augustine Oral & Facial Surgical Center
Health History
(ALL RESPONSES ARE KEPT CONFIDENTAIL)
Please answer all questions
Are you in good health
*
Yes
No
Has there been any change in your general health in the past year?
*
Yes
No
Date of last physical exam
-
Month
-
Day
Year
Date
Are you now under a physician’s care or a particular problem
*
Yes
No
Have you ever had any serious illnesses, operations or hospitalizations?
*
Yes
No
If so please describe
*
Are you allergic or have you had an adverse reaction to:
Local Anesthesia (Novocain etc….)
*
Yes
No
Penicillin or other antibiotics
*
Yes
No
Sedatives or barbiturates
*
Yes
No
Aspirin or Ibuprofen
*
Yes
No
Codeine or other pain killers
*
Yes
No
Latex or rubber gloves
*
Yes
No
Other allergies or reactions
*
Yes
No
Please List
*
Do you take or have you ever taken any bisphosphonates: Editronate (didronel), Tiludronate (Skelid), Alendronate (Fosamax), Risedronate (Actonel), Ibandronate (Boniva), Pamidronate (Aredia), Zoledronate (Zometa), Zoledronic acid (Reclast), Denosumab (Prolia), Bevacizumab (Avastin)
*
Yes
No
Do you smoke or chew tobacco
*
Yes
No
If so, how much per day?
*
Is there any past history of alcohol or chemical Dependency or emotional disorders that may effect the care we provide
*
Yes
No
Have you or any immediate family member had any problem associated with intravenous anesthesia?
*
Yes
No
Do you have any other disease, condition or problem not listed above that the doctor should know about?
*
Yes
No
Do you wish to talk to the doctor privately about anything?
*
Yes
No
Do you have or have you ever had :
Heart (Surgery, disease, attack, Pacemaker)
*
Yes
No
High Blood Pressure
*
Yes
No
Chest Pain
*
Yes
No
Heart Murmur
*
Yes
No
Mitral Valve Prolapse
*
Yes
No
Rheumatic Fever
*
Yes
No
Swollen Ankles
*
Yes
No
Active Tuberculosis
*
Yes
No
Prolonged Cough 3-4 weeks
*
Yes
No
Bloody Cough
*
Yes
No
Unexplained weight loss
*
Yes
No
Night sweats
*
Yes
No
Emphysema
*
Yes
No
Other respiratory illness
*
Yes
No
Asthma
*
Yes
No
Seizures, Epilepsy, or Convulsions
*
Yes
No
Fainting or Dizziness
*
Yes
No
Bleeding disorder, Anemia, Bleeding tendency or Blood transfusion
*
Yes
No
Do you bruise easily
*
Yes
No
Liver Disease (Jaundice, Hepatitis)
*
Yes
No
Kidney Disease
*
Yes
No
Diabetes
*
Yes
No
Thyroid Disease (Goiter)
*
Yes
No
Arthritis
*
Yes
No
Glaucoma
*
Yes
No
Implants Placed anywhere in your body
*
Yes
No
Radiation (X-Ray) treatment for Cancer Jaw Pain or clicking, popping, difficulty
*
Yes
No
Difficulty opening, grinding, clenching teeth
*
Yes
No
Sinus or nasal problems
*
Yes
No
Any disease, drug, or transplant operation that has depressed your immune system
*
Yes
No
Syphilis
*
Yes
No
Venereal Disease
*
Yes
No
Herpes
*
Yes
No
AIDS
*
Yes
No
Cold Sores/Fever blisters
*
Yes
No
FOR WOMEN ONLY
Are you pregnant, or is there a chance you might be?
*
Yes
No
If you are using ORAL CONTRACEPTIVES, it is important that you understand that antibiotics and some other medications, may interfere with the effectiveness of oral contraceptives, Therefore you will need to use mechanical forms of birth control for one complete cycle of birth control pills after the course of the antibiotics or other medications is completed Please consult with your physician if further guidance is needed.
Patient’s initials.
Are you on Depo-Provera Injections?
*
Yes
No
Medication Reconciliation Record
Please list all prescriptions, over the counter, vitamins, and herbal/natural medications that you are currently taking.
NOTE: (Last two columns to be completed by Dr. Johnson)
Click "Add Row" for more add
*
Signature of Patient
*
Name
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: