Microsoft word - hbomfs-medicalhistory.docx

MEDICAL HISTORY
Patient Name__________________________________________________________________________________________________ Date of Birth _____________________ Age _________ Weight _______________________ Height ___________________________ EMERGENCY INFORMATION
Physician ____________________________________________________________ Relative Name ________________________________________________________ Relationship ___________________________ Address ______________________________________________________________ 1. Are you having pain or discomfort at this time? …………………………………………………………………………………. YES 2. Have you ever had a bad experience in the dentistry office? What? ___________________________________________________________ YES 3. Have you been a patient in the hospital during the past two years? For what? ___________________________________________________________________________________________________________________ 4. Have you been under the care of a medical doctor during the past two years? For what? ___________________________________________________________________________________________________________________ 5. Have you taken any medicine or drugs during the past two years? What? ___________________________________________________________________________________________________________________ 6. Have you ever taken any bisphosphonate medication (Boniva, Aredia, Zometa, Fosamax, Actonel, Didronel, Skelid) for osteoporosis, bone disease, or cancer? __________________________________________________________________________ 7. Have you taken Viagra, Levitra, or Cialis in the past 48 hours? _______________________________________________________________ YES 8. Are you allergic to (i.e., itching, rash, swelling of hands, feet or eyes) or made sick by penicillin, aspirin, codeine, or any drugs or medications? If so, what ___________________________________________________________________________________________________________________ 9. Have you ever had any excessive bleeding requiring special treatment? ………………………………………………………………………………. YES 10. Please circle YES or NO to the following: Heart Failure 11. When you walk up stairs or take a walk, do you ever have to stop because of pain in your chest. or shortness of breath, or because you are very tired? ………………………………………………………………………………………………………… YES 12. Do your ankles swell during the day? ………………………………………………………………………………………………………………………. YES 13. Do you use more than 2 pillows to sleep? …………………………………………………………………………………………………………………. YES 14. Have you lost or gained more than 10 pounds in the past year? ………………………………………………………………………………………… YES 15. Do you ever wake up from sleep short of breath? …………………………………………………………………………………………………………. YES 16. Are you on a special diet? ……………………………………………………………………………………………………………………………………. YES 17. Do you take diet pills (i.e. Phen Fen)? ………………………………………………………………………………………………………………………. YES 18. Has your medical doctor ever said you have a cancer or tumor? ………………………………………………………………………………………… YES 19. Do you have any disease, condition, or problem not listed? ……………………………………………………………………………………………… YES 20. WOMEN: Are you pregnant now? ……………………………………………………………………………………………………………………………. YES Is there a possibility you are pregnant: …………………………………………………………………………………………………………. YES Are you nursing? …………………………………………………………………………………………………………………………………… YES Are you taking any oral contraceptives …………………………………………………………………………………………………………. YES 21. Are you wearing contact lenses? ……………………………………………………………………………………………………………………………. YES 22. Do you smoke? How much? _________________________________________________________________________________________ YES NO To the best of my knowledge, all of the preceding answers are true and correct. If I ever have any change in my health, or if my medicines change, I will inform the doctor of dentistry at the next appointment without fail. ________________________________________________________________________________ Signature of Patient, Parent or Guardian ……………………………………………………………………………………………………………………………………………………………………………………. MEDICAL HISTORY/PHYSICAL EVALUATION UPDATE
____________________________________________________________________________ YES NO ____________________________________________________________________________ YES NO ____________________________________________________________________________ YES NO ____________________________________________________________________________ YES NO ____________________________________________________________________________ YES NO ____________________________________________________________________________ YES NO

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