University of the Pacific School of Dentistry

HEALTH HISTORY

Patient Name:Soc. Sec. No.:

Birth Date:

I. CIRCLE APPROPRIATE ANSWER (leave Blank if you do not understand question):

1.YesNoIs your general health good?

2.YesNoHas there been a change in your health within the last year?

3.YesNoHave you been hospitalized or had a serious illness in the last three years?

If YES, why?

4.YesNoAre you being treated by a physician now? For what?

Date of last medical exam?Date of last Dental exam

5.YesNoHave you had problems with prior dental treatment?

6.Yes NoAre you in pain now?

II. HAVE YOU EXPERIENCED:

7.YesNoChest pain (angina)? 18.YesNoDizziness?

8.Yes NoSwollen ankles? 19.YesNoRinging in ears?

9.YesNoShortness of breath? 20.YesNoHeadaches?

10.YesNoRecent weight loss, fever, night sweats? 21.YesNoFainting spells?

11.YesNoPersistent cough, coughing up blood? 22.YesNoBlurred vision?

12.YesNoBleeding problems, bruising easily? 23.YesNoSeizures?

13.YesNoSinus problems? 24.YesNoExcessive thirst?

14.YesNoDifficulty swallowing? 25.YesNoFrequent urination?

15.YesNoDiarrhea, constipation, blood in stools? 26.YesNoDry mouth?

16.YesNoFrequent vomiting, nausea? 27.YesNoJaundice?

17.YesNoDifficulty urinating, blood in urine? 28.YesNoJoint pain, stiffness?

III. DO YOU HAVE OR HAVE YOU HAD:

29.YesNoHeart disease? 40.YesNoAIDS

30.YesNoHeart attack, heart defects? 41.YesNoTumors, cancer?

31.YesNoHeart murmurs? 42.YesNoArthritis, rheumatism?

32.YesNoRheumatic fever? 43.YesNoEye diseases?

33.YesNoStroke, hardening of arteries? 44.YesNoSkin diseases?

34.YesNoHigh blood pressure? 45.YesNoAnemia?

35.YesNoAsthma, TB, emphysema, other lung diseases? 46.YesNoVD (syphilis or gonorrhea)?

36.YesNoHepatitis, other liver disease? 47.YesNoHerpes?

37.YesNoStomach problems, ulcers? 48.YesNoKidney, bladder disease?

38.YesNoAllergies to: drugs, foods, medications, latex? 49.YesNoThyroid, adrenal disease?

39.YesNoFamily history of diabetes, heart problems, tumors? 50.YesNoDiabetes?

IV. DO YOU HAVE OR HAVE YOU HAD:

51.YesNoPsychiatric care? 56.YesNoHospitalization?

52.YesNoRadiation treatments? 57.YesNoBlood transfusions?

53.YesNoChemotherapy? 58.YesNoSurgeries?

54.YesNoProsthetic heart valve? 59.YesNoPacemaker?

55.YesNoArtificial joint? 60.YesNoContact lenses?

V. ARE YOU TAKING:

61.YesNoRecreational drugs? 63.YesNoTobacco in any form?

62.YesNoDrugs, medications, over-the-counter medicines 64.YesNoAlcohol?

(including Aspirin), natural remedies?

Please list:

VI. WOMEN ONLY:

65.YesNoAre you or could you be pregnant or nursing? 66.YesNoTaking birth control pills?

VII. ALL PATIENTS:

67.YesNoDo you have or have you had any other diseases or medical problems NOT listed on this form?

If so, please explain:

To the best of my knowledge, I have answered every question completely and accurately. I will inform my dentist of any change in my health and/or medication.

Patient’s signature:Date:

RECALL REVIEW:

1. Patient’s signatureDate:

2. Patient’s signatureDate:

3. Patient’s signatureDate: