PATIENT NAME DATE Reason for visit today: 1. Are you in good health?.............Y N 2. Have there been any changes in your general health in the past year?...........Y N 3. Are you under a physician’s care?...............Y N-----If yes, explain 4. Name of physician(s): 5. Do you have any of the following conditions? Rheumatic fever disease Heart attack Heart surgery High blood pressure Artificial Heart Valves Asthma Chronic cough Pneumonia Sinus/nasal problems Convulsions Dizziness Fainting Bleeding disorder Blood transfusion Liver disease Kidney disease Thyroid disease Stomach ulcer/colitis Artificial joints/implants Chemotherapy Popping in jaw Difficulty opening mouth Congenital heart disease Heart murmur/Mitral valve Angina (chest pain) Pacemaker Stroke Emphysema Bronchitis Shortness of breath Seizures Epilepsy Psychiatric treatment Nervous disorder Anemia Bruising easily Hepatitis, Type Diabetes Arthritis Glaucoma Radiation treatment Mouth sores Pain in ear Grinding/clenching teeth 6. If you have had or presently have a condition, illness, operation, or hospitalization not listed above-Please describe: 7. If you have asthma, do you have your inhaler with you? 8. Please list all medications taken at this time: 9. Have you been on any biphosphonates currently or in the past? If so, please check which type. (Oral) Actonel BonivaFosamax Skelif Didronel (I.V) Aredia Zometa 10. Have you been on any chemotherapy medications currently or in the past? Yes or No List name of medcation: 11. Please list any medications you are allergic to: 12. Are you pregnant?.................Y N 13. Do you smoke?......................Y N 14. Do you chew tobacco?......................Y N DENTAL HISTORY Is your condition causing you discomfort?....................................... Y N Do you have swelling?.......................................................................Y N Is this the result of trauma? Y N If yes, describe Do you feel nervous about dental treatment?.....................................Y N Have you ever had a bad experience in a dental office?....................Y N Do you have other dental problems?..................................................Y N Does your jaw ever lock, pop, or click?.............................................Y N Are your teeth sensitive?....................................................................Y N Is there anything you wish to discuss privately with the doctor? Y N I understand the importance of a truthful health history to assist the doctor in providing the best care possible. I have had the opportunity to discuss my health history with my doctor. To the best of my knowledge, all the preceding answers are true and correct. If I have any change in my medical history, dental history, or if my medications change, I will inform the doctor. I understand that failure to disclose any medical condition may jeopardize my life. Signature of Person Completing Health History Date