HEALTH HISTORY
Physician's Name
Date of last visit
-
Month
-
Day
Year
Date
Have you ever used a bisphosphonate medication? Common brand names are Fosamax, Actonel, Atelvia, Didronel, Boniva.
Yes
No
Have you ever taken any of the group of drugs collectively referred to as “fen-phen?” These include combinations of Ionimin, Adipex, Fastin (brand names of phentermine), Pondimin (fenfluramine) and Redux (dexfenfluramine).
Yes
No
Place a mark on “yes” or “no” to indicate if you have had any of the following:
Rows
Yes
No
AIDS/HIV
Anemia
Arthritis, Rheumatism
Artificial Heart Valves
Artificial Joints
Asthma
Back Problems
Bleeding abnormally, with extractions or surgery
Blood Disease
Cancer
Chemical Dependency
Chemotherapy
Circulatory Problems
Congenital Heart Lesions
Cortisone Treatments
Cough, persistent or bloody
Diabetes
Emphysema
Epilepsy
Fainting or dizziness
Glaucoma
Headaches
Heart Murmur
Heart Problems
Herpes
High Blood Pressure
Jaundice
Jaw Pain
Kidney Disease
Liver Disease
Low Blood Pressure
Mitral Valve Prolapse
Nervous Problems
Pacemaker
Psychiatric Care
Radiation Treatment
Respiratory Disease
Rheumatic Fever
Scarlet Fever
Shortness of Breath
Sinus Trouble
Skin Rash
Special Diet
Stroke
Swollen Feet or Ankles
Swollen Neck Glands
Thyroid Problems
Tonsillitis
Tuberculosis
Tumor or growth on head or neck
Ulcer
Venereal Disease
Weight Loss, unexplained
Have you had Hepatitis?
Yes
No
Hepatitis Type
Do you wear contact lenses?
Yes
No
Women:
Are you pregnant?
Yes
No
Due date
-
Month
-
Day
Year
Date
Are you nursing?
Yes
No
Taking birth control pills?
Yes
No
MEDICATIONS
List any medications you are currently taking and the correlating diagnosis:
Pharmacy Name
Phone
Please enter a valid phone number.
Format: (000) 000-0000.
ALLERGIES
Aspirin
Barbiturates (Sleeping pills)
Codeine
Iodine
Latex
Local Anesthetic
Penicillin
Sulfa
Other
UPDATES
To be filled in at future appointments
Has there been any change in your health since your last dental appointment?
Yes
No
For what conditions?
Are you taking any new medications?
Yes
No
If so, what?
Patient's Signature
Date
-
Month
-
Day
Year
Date
Doctor's Signature
Date
-
Month
-
Day
Year
Date
Has there been any change in your health since your last dental appointment?
Yes
No
For what conditions?
Are you taking any new medications?
Yes
No
If so, what?
Patient's Signature
Date
-
Month
-
Day
Year
Date
Doctor's Signature
Date
-
Month
-
Day
Year
Date
Submit
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