Microsoft word - health history.doc

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HOW WOULD YOU ASSESS YOUR GENERAL HEALTH? o GOOD o FAIR o POOR
To ensure your well being while undergoing treatment in our office, please answer the following questions in
detail. All information will be considered confidential and for our records only.


Are you currently seeing a physician for treatment Diabetes
of a recent or ongoing medical condition? Have you been hospitalized within the last year? Artificial joint(s) yes o no o
Have you had a serious illness or operation within o o Hepatitis
Have you ever had any serious medical trouble Have you ever been advised to take antibiotics (like penicillin, etc.,) before a dental appointment? If yes, explain: o Have reason to suspect you have been exposed Do you now or have you had any of the following cardio-
vascular diseases? yes o no o
Tuberculosis (TB) yes o no o
Check any that apply;
Rheumatic fever or rheumatic heart disease o Shortness of breath after mild exercise o Shortness of breath when you lie down Abnormal bleeding or extended clotting time o Currently taking Fosamax, Boniva or Actonel, o Previously taken Fosamax, Boniva or Actonel, Do you consider yourself currently under
If you currently take these medications, check the
an abnormally high amount of stress?
box on the left and list the name of medication. If
you have taken any of these medications within the
past year, but are not taking them currently, check
the box on the right.
o Antibiotics ___________________________ o o Antidepressants (such as Prozac, Zoloft, etc.) o o Antihistamines _______________________ o o Blood pressure medication _____________ o o Blood thinners _______________________ o If you currently smoke, how much? _______________ If you were a smoker, when did you quit? __________ o Cholesterol medication ________________ o o Decongestants _______________________ o o Diuretics (water pills) __________________ o o Insulin _____________________________ o W O M E N O N L Y

If yes, expected delivery date ______________ o Muscle relaxants _____________________ o o Pain medication (Aspirin, Advil, Tylenol) o Sleeping pills ________________________ o Are you on hormone replacement therapy? o o o Thyroid medication ____________________ o o Tranquilizers _________________________ o o Vitamins ____________________________ o o Others ______________________________ o ____________________________________ Are you ALLERGIC to any of the
following, please circle or list
medication (get hives, a rash, have
trouble breathing, etc.):
o Antibiotics (penicillin, tetracycline)
______________________________
o Local dental anesthetics (novocain)
______________________________
PATIENT SIGNATURE
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o Latex o Others _________________________ ______________________________ condition or medical problem not listed you feel we should

Source: http://www.drjonwilkins.com/assets/documents/nonglobal/resources/Health-History.pdf