CONFIDENTIAL HEALTH HISTORY
First NameFirst Name is a required field
Last NameLast Name is a required field
Invalid Date of Birth. Format MM/dd/yyyy
BirthdateBirthdate is a required field
Is your general health good ?
If No, Explain:
Has there been a change in your health within the last year?
If Yes, Explain:
Have you gone to the hospiltal or emergencey room or had a seriour illness in the last three years?
If Yes, Explain:
Are you being treated by a physician now?
If Yes, Explain:
Date of last medical exam?
Reasons for exam
Have you had problems with prior dental treatment?
If Yes, Explain:
Date of last dental exam?
Name of last reating dentist:
Are you in pain now?
If Yes, Explain:
II. HAVE YOU EVER EXPERIENCED ANY OF THE FOLLOWING?
( Please check Yes or No for each)
Chest pain (angina)
Blood in stools
Frequent vomiting
Fainting or Dizzy Spells
Diarrhea or constipation
Jaundice
Recent Significant wieght loss
Frequent urination
Dry mouth
Fever
Difficulty urinating
Excessive thirst
Night sweats
Ringing in ears
Difficulty swallowing
Persistent cough
Headaches
Swollen ankles
Coughing up blood
Blurred Vision
Joint pain or stiffeness
Bleeding problems
Dizziness
Shortness of breath
Blood in urine
Bruise Easily
Sinus Problems
Other:
III. HAVE YOU EVER HAD OR DO YOU HAVE ANY OF THE FOLLOWING?
( Please check Yes or No for each)
Heart Disease
AIDS/HIV
Pyschiatric Care
Family history of heart disease
Surgeries
Osteoporosis
Heart Attack
Hospitalization
Thyroid Disease
Artificial Joint/Hip or Knee
Diabetes
Asthma
Type/Date of surgery:
Stomach trouble/ulcers
Family history of diabetes
Hepatitis
Heart defects
Tumors or cancer
Sexually transmitted disease
Heart Pacemaker
Date implanted:
Heart Murmur
Chemotherapy (Cancer/Leukemia)
Herpes
Rheumatic Fever
Radiation
Canker or cold sores
Skin disease
Arthritis
Anemia
Hardening of arteries
Emphysema or other lung disease
Liver disease
High Blood Pressure
Kidney or bladder disease
Eye disease
Seizures
Stroke
Transplants
Cosmetic Surgery
Eating disorders
Tuberculosis (TB)
Other:
IV. ARE YOU ALLERGIC TO OR HAVE YOU HAD A REACTION TO ANY OF THE FOLLOWING?
( Please check Yes or No for each)
Aspirin
Valium or sedatives
Codeine or other opioids
Penicillin or other antibiotics
Latex products
Food
Blood in urine
Local anesthetic
Metals/nickles/jewelry
Other:
V. ARE YOU TAKING OR HAVE YOU TAKEN ANY OF THE FOLLOWING IN THE LAST THREE MONTHS?
( Please check Yes or No for each)
Recreational drugs
Tobacco in any form
Antibiotics
Over-the-counter medicines
Alcohol
Supplements
Weight loss medications
Bisphosphonate (Fosamax)
Aspirin
Antidepressants
Herbal supplements
Opioids (e.q.,Norco, Vicodin, Percocet, Percodan)
If YES, please explain reason:
Please list all prescriptions medications:
VI. WOMEN ONLY
( Please check Yes or No for each)
Pregnant
If YES, how many months:
Nursing
Birth control user
VII. ALL PATIENTS
( Please check Yes or No for each)
Do you have or have you had any other diseases or medical problems NOT listed on this form?
If YES, please explain reason:
Have you ever been pre-medicated for dental treatment?
If YES, why:
Have you tested positive for COVID-19?
If YES,date of positive test result:
Are you experiencing any ongoing or lasting symptoms or effects as a result?
If YES, what are these symptoms or effects?
Are you currently under the care of a physician or taking any medications for any of the conditions listed above?
If YES,date of positive test result:
If patient answers ββyesββ to any of the questions above, consider seeking additional information from the patient regarding their symptoms and medications, prior to treatment.
Are there any issues or conditions that you would like to discuss with the dentist in private?.
The practice of dentistry involves treating the whole person. If the dentist determines that there may be a potentially medically- compromised situation, medical consultation may be needed prior to commencement of dental treatment.
I authorize the dentist to contact my physician.
Date
Physician's Name:
Phone Number:
Whom would you like us to contact in case of an emergency?)
Emergancy Contact Name:
Emergency Contact Relationship Status:
Emergancy Contact Phone Number:
I certify that I have read and understand this form. 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. Further, I will not hold my dentist, or any other member of his/her staff, responsible for any errors or omissions that I may have made in the completion of this form.
Date
Date