Patients Name

HEALTH HISTORY

Patients Name:

Place a mark on ‘Yes’ or ‘No’ to indicate if you have had any of the following:

AIDS ÿ Yes ÿ No Epilepsy ÿ Yes ÿ No Psychiatric Care ÿ Yes ÿ No

Anemia ÿ Yes ÿ No Fainting or dizziness ÿ Yes ÿ No Radiation Treatment ÿ Yes ÿ No

Arthritis, Rheumatism ÿ Yes ÿ No Glaucoma ÿ Yes ÿ No Respiratory Disease ÿ Yes ÿ No

Artificial Heart Valves ÿ Yes ÿ No Headaches ÿ Yes ÿ No Rheumatic Fever ÿ Yes ÿ No

Artificial Joints ÿ Yes ÿ No Heart Murmur ÿ Yes ÿ No Scarlet Fever ÿ Yes ÿ No

Asthma ÿ Yes ÿ No Heart Problems ÿ Yes ÿ No Shortness of Breath ÿ Yes ÿ No

Back Problems ÿ Yes ÿ No Hepatitis ÿ Yes ÿ No Sinus Trouble ÿ Yes ÿ No

Bleeding Abnormally, with Type ______Skin Rash ÿ Yes ÿ No

extractions or surgery ÿ Yes ÿ No Herpes ÿ Yes ÿ No Special Diet ÿ Yes ÿ No

Blood Disease ÿ Yes ÿ No High Blood Pressure ÿ Yes ÿ No Stroke ÿ Yes ÿ No

Cancer ÿ Yes ÿ No HIV Positive ÿ Yes ÿ No Swelling of Feet or

Chemical Dependency ÿ Yes ÿ No Jaundice ÿ Yes ÿ No Ankles ÿ Yes ÿ No

Chemotherapy ÿ Yes ÿ No Jaw Pain ÿ Yes ÿ No Swollen Neck Glands ÿ Yes ÿ No

Circulatory Problems ÿ Yes ÿ No Kidney Disease ÿ Yes ÿ No Thyroid Problems ÿ Yes ÿ No

Congenital Heart Lesions ÿ Yes ÿ No Liver Disease ÿ Yes ÿ No Tonsillitis ÿ Yes ÿ No

Cortisone Treatments ÿ Yes ÿ No Low Blood Pressure ÿ Yes ÿ No Tuberculosis ÿ Yes ÿ No

Cough, persistent or Mitral Valve Prolapse ÿ Yes ÿ No Tumor or growth on

Bloody ÿ Yes ÿ No Nervous Problems ÿ Yes ÿ No head or neck ÿ Yes ÿ No

Diabetes ÿ Yes ÿ No Pacemaker ÿ Yes ÿ No Ulcer ÿ Yes ÿ No

Emphysema ÿ Yes ÿ No Women: Venereal Disease ÿ Yes ÿ No

Blood Thinner Are you pregnant ? ÿ Yes ÿ No Weight Loss, ÿ Yes ÿ No

medication like asprin? ÿ Yes ÿ No Due date ______unexplained

Are you nursing? ÿ Yes ÿ No Previous Fosamax ,Boniva,Actonel or any cancer

medications containing bisphosphonates use? ÿ Yes ÿ No

MEDICATIONS ALLERGIES

List medications you are currently taking: ÿ Aspirin ÿ Local Anesthetic

______ÿ Barbiturates ÿ Penicillin

______ÿ Codeine ÿ Sulfa

______ÿ Iodine ÿ Other ______ÿ Latex ______

______

Physician’s Name and Phone #: ______

I CERTIFY THAT THE ABOVE INFORMATION IS COMPLETE AND ACCURATE.

Date: ______Signature: ______Dr’s initial: ______

Updates (To be filled in at future appointments)

Has there been any change in your health since your last dental appointment? ÿ Yes ÿ No

For what conditions?______

Are you taking any new medications?______If so______

Patient initial______Date______Doctor’s initial______Date______

Patient initial______Date______Doctor’s initial______Date______

Patient initial______Date______Doctor’s initial______Date______