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 

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