Health History Step 1 of 3 33% Patient Name* First Last Birth Date* MM DD YYYY Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you have, or medication that you may be taking,Emergency Contact Name/PhoneEmergency Contact Name*Emergency Phone Number*Who is your primary physician? and Phone NumberPhysician Name*Physician Phone*Who is your previous dentist?*Whom may we thank for referring you?*Date of last physical exam? Date Format: MM slash DD slash YYYY Have you been hospitalized in the past five years? If yes, why?*YesNoHospitalized in the past five years MedicationsDo you take, or have you used, Phen-fen or Redux?*YesNoDo you take bone density medications?Actonel*YesNoAredia*YesNoAtelvia*YesNoBoniva*YesNoBinosto*YesNoDidronel*YesNoDonefoe*YesNoFosamax*YesNoRedast*YesNoSkelid*YesNoZometa*YesNoIf other bone density medications, please listAre you taking any blood thinners?Asprin*YesNoCoumadin/Warfarin*YesNoEliquis*YesNoHeparin*YesNoPradaxa*YesNoXarelto*YesNoIf other blood thinner, please listAre you allergic to:Penicillin*YesNoClindamycin*YesNoMetal Sensitivity*YesNoLatex*YesNoTetracycline*YesNoIf other allergy medications, please listAre you taking any medications?*YesNoIf others, please listDo you use Tobacco?*YesNoIf yes, How long? How much and what type?Do you use controlled substances?*YesNoIf yes, what substances?Women: Are you.. Pregnant/Trying to get pregnant Nursing Taking oral contraceptives Do you have, or have you had, any of the following?AIDS/HIV Positive*YesNoAlzheimer's Disease*YesNoAnemia*YesNoArtifical Heart Valve*YesNoAsthma*YesNoStroke*YesNoMitral Valve Prolapse*YesNoTuberculosis*YesNoCongenital Heart Disorder*YesNoSteroid Medicine*YesNoDiabetes*YesNoHerpes*YesNoExcessive Bleeding*YesNoFainting Spells/Dizziness*YesNoBruise Easily*YesNoChest Pains*YesNoCold Sores/Fever Blisters*YesNoUlcers*YesNoHemophilia*YesNoDrug/Alcohol Additions*YesNoHigh Blood Pressure*YesNoArtificial Joint*YesNoSinus Trouble*YesNoCancer*YesNoHeart Attack/Failure*YesNoHeart Murmur*YesNoHeart Trouble/Disease*YesNoRadiation Treatments*YesNoHepatitis B or C*YesNoEpilepsy or Seizures*YesNoHypoglycemia*YesNoBreathing Problems*YesNoChemotherapy*YesNoOsteoporosis*YesNoPain in Jaw Joints*YesNoPsychiatric Care*YesNoDo you have any physical or medical conditions not listed above?If yes, please list Dental HistoryDo you have specific problems?*YesNoIf yes, please describeHas fear of discomfort kept you from dental visits?*YesNoDo your gums bleed?*YesNoDo you clench or grind your teeth?*YesNoHave you ever had the followingInjury to face, jaws or teeth*YesNoOrthodontics*YesNoOral Surgery*YesNoPeriodontal (gum) Treatment*YesNoDo you take fluoride supplements?(children)YesNoDo you have a Medical Power of Attorney?*YesNoIf yes, who?Consent I agree to this Health History.To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in my medical status.
