Health History Form

As required by law, our office adheres to written policies and procedures to protect the privacy of information about you that we create, receive or maintain,. Your answers are for our records only and will be kept confidentiaal subject to applicable laws. Please not that you will be asked some questions about your responses to this questionnaire and there may be additional questions cencerning your health. This information is vital to allow us to provide appropriate care for you. This office does not use this information to discriminate.

If you are completing this form for another person, what is your relationship to that person?

Do you have any of the following diseases or problems: (Check DK if you Don't Know the answer to the question)

Active Tuberculosis

Persistent cough greater than a 3 week duration.

Cough that produces blood

Been exposed to anyone with tuberculosis

If you answer yes to any of the 4 items above, please stop and return this form to the receptionist.


Dental Information


​​​​​​​

Do your gums bleed when you brush or floss?

Are your teeth sensitive to cold, hot, sweets or pressure?

Is your mouth dry?

Have you had any periodontal (gum) treatments?

Have you ever had orthodontic (braces) treatment?

Have you had any problems associated with previous dental treatment?

Is your home water supply fluoridated?

Do you drink bottled or filtered water?

If yes, how often? Circle one: DAILY / WEEKLY / OCCASIONALLY

Are you currently experiencing dental pain or discomfort?

Do you have earaches or neck pains?

Do you have any clicking, popping or discomfort in the jaw?

Do you brux or grind your teeth?

Do you have sores or ulcers in your mouth?

Do you wear dentures or partials?

Do you participate in active recreational activities?

Have you ever had a serious injury to your head or mouth?

Date of your last dental exam:

What was done at that time?

Date of last dental x-rays

What is the reason for your dental visit today?

How do you feel about your smile?


Medical Information


​​​​​​​
Are you now under the care of a physician?
Physician Name
Phone
Address/City/State/Zip
Are you in good health?
Has there been any change in your general health within the past year?
Have you had a serious illness, operation or been hospitalized in the past 5 years?
Are you taking or have you recently taken any prescription or over the counter medicine(s)?

Do you wear contact lenses?

Joint Replacement. Have you had an orthopedic total joint (hip, knee, elbow, finger) replacement?

If yes, have you had any complications?

Are you taking or scheduled to begin taking an antiresorptive agent (like Fosamax® , Actonel® , Atelvia, Boniva® , Reclast, Prolia) for osteoporosis or Paget’s disease?

Since 2001, were you treated or are you presently scheduled to begin treatment with an antiresorptive agent (like Aredia® , Zometa® , XGEVA) for bone pain, hypercalcemia or skeletal complications resulting from Paget’s disease, multiple myeloma or metastatic cancer?

Since 2001, were you treated or are you presently scheduled to begin treatment with an antiresorptive agent (like Aredia® , Zometa® , XGEVA) for bone pain, hypercalcemia or skeletal complications resulting from Paget’s disease, multiple myeloma or metastatic cancer?

Do you use controlled substances (drugs)?

Do you use tobacco (smoking, snuff, chew, bidis)?

If so, how interested are you in stopping?

Do you drink alcoholic beverages?

If yes, how much alcohol did you drink in the last 24 hours?

If yes, how much do you typically drink i n a week?

WOMEN ONLY Are you:

Pregnant?

If yes, how much do you typically drink i n a week?

Taking birth control pills or hormonal replacement?

Nursing?

Allergies. Are you allergic to or have you had a reaction to: To all yes responses, specify type of reaction.

Local anesthetics

Aspirin

Penicillin or other antibiotics

Barbiturates, sedatives, or sleeping pills

Sulfa drugs

Codeine or other narcotics

Metals

Latex (rubber)

Iodine

Hay fever/seasonal

Animals

Food

Other

Artificial (prosthetic) heart valve

Previous infective endocarditis

Damaged valves in transplanted heart

Congenital heart disease (CHD)
Unrepaired, cyanotic CHD

Repaired (completely) in last 6 months

Repaired CHD with residual defects

Except for the conditions listed above, antibiotic prophylaxis is no longer recommended for any other form of CHD.

Cardiovascular disease

Mitral valve prolapse

Angina

Pacemaker

Arteriosclerosis

Rheumatic fever

Congestive heart failure

Rheumatic heart disease

Damaged heart valves

Abnormal bleeding

Heart attack

Heart attack

Heart murmur

Blood transfusion

if yes, date

Low blood pressure

Hemophilia

Other congenital heart defects

AIDS or HIV infection

Arthritis

Autoimmune disease

Glaucoma

Rheumatoid arthritis

Hepatitis, jaundice or liver disease

Systemic lupus erythematosus

Epilepsy

Asthma

Fainting spells or seizures

Bronchitis

Neurological disorders

If yes, specify

Neurological disorders

Emphysema

Sleep disorder

Tuberculosis

Do you snore?

Do you snore?

Cancer/Chemotherapy/ Radiation Treatment

Mental health disorders

Specify

Recurrent Infections

Type of infection

Chest pain upon exertion

Kidney problems

Chronic pain

Night sweats

Eating disorder

Osteoporosis

Malnutrition

Persistent swollen glands in neck

G.E. Reflux/persistent heartburn

Severe headaches/ migraines

Ulcers

Severe or rapid weight loss

Thyroid problems

Sexually transmitted disease

Stroke

Excessive urination

Has a physician or previous dentist recommended that you take antibiotics prior to your dental treatment?

Name of physician or dentist making recommendation

Phone: Include area code

Do you have any disease, condition, or problem not listed above that you think I should know about?

Please explain