Health History FormE-mail Today’s Date * As required by law, our office adheres to written policies and procedures to protect the privacy of information about you that we create, receive, or maintain. Your answers are for our records only and will be kept confidential subject to applicable laws. Please note that you will be asked some questions about your responses to this questionnaire and there may be additional questions concerning your health. This information is vital to allow us to provide appropriate care for you. This office does not use this information to discriminate.PATIENT INFORMATIONFirst Name * Last Name * MI Home Phone Cell Phone Work Phone Preferred Method of Contact PhoneTextEmail Mailing Address City State Zip Height Weight Date of Birth Sex —Lütfen bir seçenek seçin—FemaleMaleOtherPrefer not to sayOccupation Emergency Contact How did you hear about us? If you are completing this form for another person, what is your relationship to that person? Your Name Relationship Home Phone Cell Phone DENTAL INFORMATIONAre your teeth sensitive to cold, hot, sweets or pressure?YesNoDo you have earaches or neck pains?YesNoDoes food or floss catch between your teeth?YesNoDo you have any clicking, popping, or discomfort in the jaw?YesNoIs your mouth dry?YesNoDo you brux or grind your teeth?YesNoHave you had any periodontal (gum) treatments?YesNoDo you have sores or ulcers in your mouth?YesNoHave you ever had orthodontic (braces) treatment?YesNoDo you wear dentures or partials?YesNoHave you ever had any problems associated with previous dental treatment?YesNoDo you participate in active recreational activities?YesNoIs your home water supply fluoridated?YesNoHave you ever had a serious injury to your head or mouth?YesNoDo you drink bottled or filtered water?YesNoAre you currently experiencing dental pain or discomfort?YesNoIf yes, how often? DailyWeeklyOccasionallyDate of your last exam What was done at that time? Date of last dental x-rays Chief Complaint Reason for visit MEDICAL INFORMATIONAre you currently under the care of a physician?YesNoAre you in good health?YesNoHas there been any change in your general health within the past year?YesNoDo you take blood thinners?YesNoDo you take aspirin on a regular basis?YesNoAre you taking or scheduled to begin taking either of the medications, alendronate (Fosamax) or risedronate (Actonel) for osteoporosis or Paget’s disease?YesNoAre you taking or have you recently taken any prescription or over the counter medicine(s)?YesNoDo you use controlled substances (drugs)?YesNoDo you use tobacco (smoking, snuff, chew, bidis)?YesNoDo you drink alcoholic beverages?YesNoJoint Replacement: Have you ever had an orthopedic total joint replacement?YesNoAre you in recovery?YesNoHave you had a serious illness, operation or been hospitalized in the past 5 years?YesNoPhysician Name Phone Address/City/State/Zip If yes, what condition is being treated? Date of last physical exam If yes, list all medications, vitamins, herbal preparations and/or diet supplements: If so, how interested are you in stopping? (Tobacco) VerySomewhatNot InterestedIf yes, how much alcohol did you drink in the last 24 hours? If yes (Joint Replacement), date If yes, have you had any complications? YesNoIf yes, how long have you been in recovery? If yes, what was the illness or problem? WOMEN ONLYPregnant?YesNoNumber of weeks Nursing?YesNoTaking birth control pills or hormonal replacements?YesNoMEDICAL INFORMATION (Continued)Allergies: Are you allergic or have you had a reaction to:Local anestheticsAspirinPenicillin or other antibioticsBarbiturates, sedatives, or sleeping pillsSulfa drugsCodeine or other narcoticsMetalsHay fever/seasonalLatex (rubber)IodineAnimalsFood/OtherIf yes, please specify Please mark (X) your response if you have or have had any of the following diseases or problems.Heart murmurMitral valve prolapseArtificial heart valvesRheumatic feverCardiovascular diseaseAnginaArteriosclerosisCongestive heart failureCoronary artery diseaseDamaged heart valvesHeart attackLow blood pressureHigh blood pressureCongenital heart defectsPacemakerRheumatic heart diseaseAbnormal bleedingAnemiaBlood transfusionHemophiliaAIDS or HIV infectionArthritisAutoimmune diseaseRheumatoid arthritisSystematic lupus erythematosusAsthmaBronchitisEmphysemaSinus troubleTuberculosisCancer/Chemotherapy/Radiation treatmentChest pain upon exertionChronic painDiabetes type I or type IIEating disorderMalnutritionGastrointestinal diseaseGE Reflux/persistent heartburnUlcersThyroid problemsStrokeGlaucomaHepatitis, jaundice, or liver diseaseEpilepsyFainting spells/seizuresNeurological disordersGag Reflex SensitivitySleep disorderMental health disordersRecurrent infectionsKidney problemsNight sweatsOsteoporosisPersistent swollen glands in neckSevere headche/migrainesSevere/rapid weight lossSTDs/STIsExcessive urinationADDADHDSensory Processing DisorderOral Sensory SensitivityIf “Blood transfusion”, date If “Neurological disorders”, please specify If “Mental health disorders”, please specify If “Recurrent infections”, type of infection Has a physician recommended that you take antibiotics prior to your dental treatment?YesNoDo you have any disease, condition, or problem not listed above that we should know about?YesNoIf yes, please explain PHARMACY INFORMATIONPharmacy Name Pharmacy Phone Pharmacy Address SIGNATURE NOTE: Both Doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment. I certify that I have read and understand the above and that the information given on this form is accurate. I understand the importance of a truthful health history and that my doctor and their staff will use this information for treating me. I acknowledge that my questions, if any, about inquiries set forth above have been answered to my satisfaction. I will not hold my doctor, or any other member of their staff, responsible for any action they take or do not take because of errors or omissions that I may have made in the completion of this form.Name of Patient/Legal Guardian Date Electronic Signature (type full name) I confirm the information provided is accurate and I consent to electronic signature. All parties involved agree that this document may be signed electronically for the purposes of validity, enforceability, and admissibility.FOR COMPLETION BY OFFICEComments:
