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HEALTH HISTORY / DENTAL

Patients First Name MI Last Name Birthdate Sex

Male Female

GENERAL HEALTH QUESTIONS

1. Have you had any serious illness, operations or hospitalizations? Yes No_______________________________________________________________________________________________________________

2. Are you under a physicians care at this time? Yes NoName, address and phone # of physician:

__________________________________________________ ___________________________________________________________

Do you have or did you ever have any of the following?

Cardiovascular Health/ Muscular-Skeletal/CNS/Mental Health

3. High blood pressure Yes No 22. Joint replacement Yes No4. Heart disease, problem or treatment Yes No 23. Arthritis Yes No5. Rheumatic fever Yes No 24. Osteoporosis Yes No6. Past use of Fen-Phen Yes No 25. Fainting spells or dizziness Yes No7. Difficulty breathing when lying down Yes No 26. Seizures Yes No8. Low blood pressure Yes No 27. Multiple sclerosis Yes NoRespiratory Health 28. Anxiety/Nervousness Yes No

9. Asthma Yes No Gastro-Intestinal/Genito-Urinary Health

10.Chronic sinus problems Yes No 29. Hepatitis (A, B, C or other) Yes No

Endocrine/ Blood /Immune Health 30. Kidney disease/dialysis Yes No

11. Diabetes Yes No 31. Stomach trouble/ulcers Yes No

12. Frequent thirst or frequent urination Yes No Medication Allergies and Other Allergies

13. Thyroid problems Yes No 32. Penicillin or other antibiotics Yes No

14. Abnormal bleeding, bruise easily Yes No 33. Sulfa drugs Yes No

15. Hemophilia Yes No 34. Dental anthesthetic Yes No

16. Anemia/blood disease Yes No 35. Aspirin Yes No

17. Cancer Yes No 36. Codeine/narcotics Yes No

18. Radiation therapy/chemotherapy Yes No 37.Iodine Yes No

19. HIV infections/AIDS Yes No 38. Latex products Yes No

20. Organ transplant Yes No 39. Metals/nickels/jewelry Yes No

21. Blood transfusion Yes No 40. Other: Yes No

_____________________________________

Females Only

41. Are you pregnant? Yes No42. Are you nursing now? Yes No43. Do you take birth control pills? Yes No

Medications60. Are you taking any prescription medications, over the counter medications or herbal medicines? Yes No

If so, please list them and the dose taken:

______________________________________________________________________________________________________________

61. Do you or have you used bisphosphonate medication (Fosomax, Actonel, Boniva, Skelid, Didronel, Aredia, Zometa, Bonefos)? Yes No

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Social

62. Do you use tobacco? Yes No Quantity ____________ Per Day

63. Do you use alcohol? Yes No Quantity _____________ Per Day Per Week

64. Do you use recreational drugs? Yes No Quantity ____________ Per Day

65. Do you have any other medical conditions not listed above?

Please list:

___________________________________________________________________________________________________________

I hereby certify that I have read the foregoing and filled out this questionnaire completely. I have advised you of all medical problems of which I

am aware. I further certify that I, the undersigned, consent to the performing of x-rays and examination.

Signature of PATIENT or GUARDIAN ________________________ Date __________

Signature of DENTIST __________________________ ID # ____________ Date __________

UPDATE Have there been any changes in your medical history, including any medications that you take, since you last

completed this form? Yes NoSignature of PATIENT or GUARDIAN Signature of DENTIST

____________________________ Date ____________ ________________________ Date ___________