Chicocosmeticdentist.com

HEALTH HISTORY
Name ______________________________________________ Date _____________________________ Date of last health care exam: ________________What was this exam for?_________________________ Have you been hospitalized in the last 5 years? (Please circle) If yes, reason:__________________________________________________________________________ Are you currently receiving care? If yes, nature of care: _________________________ Please list all the names and phone numbers of the physicians who are currently providing you care: 1. ____________________________________________________________________ 2. ____________________________________________________________________ 3. ____________________________________________________________________ For the following questions circle yes or no. Your answers are for our records only and will be confidential. Please note that during your initial visit you will be asked some questions about your response. Our team may ask additional questions concerning your health. Anemia or Blood Disorder? Arthritis, Rheumatism or other inflammatory Emphysema or other Respiratory/Lung Illnesses Endocarditis Heart Valve (artificial) or Heart Transplant Heart Disease, Heart Attack, Heart Surgery Are you taking any of these medications? Pre-medication before dental Yes Tagamet® (cimetidine) or Prilosec® Yes Cardizem® (diltiazem) or Calan, Isoptin® Yes Diflucan® (fluconazole) or Sporonox® Have you been treated with Bisphosphonate drugs (Fosamax®, Aredia®, Zometa®, Actonel®, Boniva®)? If so, when did the treatment begin? ___________ When did the treatment end? _____ Have you ever taken any prescription drugs such as fen-phen for weight loss? Do you consume grapefruit juice, grapefruits or grapefruit extract? Please list any medications you are currently taking and dosages: _____________________________________ _______________________________________ _____________________________________ _______________________________________ _____________________________________ _______________________________________ _____________________________________ _______________________________________ _____________________________________ _______________________________________ Please list any dietary or herbal supplements you are taking, and for what purpose: _____________________________________ _______________________________________ _____________________________________ _______________________________________ _____________________________________ _______________________________________ Women: Are you pregnant? If no, are you planning a pregnancy in the near future? Abnormal Blood Pressure? (Please circle) Have you ever received a diagnosis of “high blood pressure”? What is your normal blood pressure? Are you allergic or have you had a reaction to: a. Local anesthetics ………………………………………………………. No b. Penicillin or other antibiotics …………………………………………… No c. Aspirin, Ibuprofen or Tylenol ….……………………………………… No d. Codeine, Valium or other sedatives…………………………………… No e. Latex or Metals f. Other (please specify)____________________________________________________ Tobacco, Alcohol, Drugs Do you use tobacco? If yes, circle type: smoke chew How much per day? _______ For how long? ___________ Do you want to quit using tobacco? Do you consume alcohol? If yes, approximately how many alcoholic beverages per week? ____ No Do you use any mood altering drugs other than those previously listed? Sugar in your diet (circle one): none slight moderate high I understand the above information is necessary to provide me with dental care in a safe and efficient manner. I have answered all questions to the best of my knowledge. Should further information be needed, you have my permission to ask the respective health care provider or agency, who may release such information to you. I will notify the doctor of change in my health and medication. _______________________________ ____________________________ _______________________________ ____________________________

Source: http://www.chicocosmeticdentist.com/docs/Form_Health%20History.pdf