WELCOME! HEALTH HISTORY Dellin R. Bakkum, DDS Please complete BOTH sides. Date:_______ Name:_____________________________________________ Phones: _____________ Last Medical Exam:_________ Your Physician:_____________________________ Phone:_________ Second Physician:___________________ Phone:_________ Were you hospitalized in the last 5 years? Reason(s)____________________________________________ Have you had surgery in the last 5 years? Procedure(s)_________________________________________ Are you currently under medical care? For_________________________________________________ For the following questions, please circle no or yes. Your answers are for our records only and will be confidential. Please note that during your initial visit you will be asked some questions about your responses. Our team may ask additional questions concerning your health.
Arthritis, Rheumatism or other inflammatory disease?
Abnormal Heart or Previous Bacterial Endocarditis?
Heart Valve (artificial) or Heart Transplant
Heart Disease, Heart Attack, Heart Surgery?
Please list any medications you are currently taking, and for what purpose: Medication and Dose Reason You Are Taking It (Doctor's Use) Dental Implications Please list any dietary or herbal supplements you are taking, and for what purpose: Supplement Reason You Are Taking It (Doctor's Use) Dental Implications Please complete side 2. Thank you! Are you taking any of these medications?
Tagamet (Cimetidine) or Prilosec (Omeprazole)? No Yes
Diltiazem (Cardizem) or Verapamil (Calan, Isoptin)? No Yes
Fluconazole (Diflucan) or Itraconazole (Sporonox)? No Yes
Do you eat grapefruit or drink grapefruit juice?
Have you ever taken any prescription drugs (such as fen-phen) for weight loss?
Have you ever been treated with a bisphosphonate drug (Fosamax, Aredia, Zometa, Actonel, Boniva)? If so, when No Yes
did the treatment begin? When did the treatment end?
Women:
Is there a chance that you might become pregnant in the near future?
Have you had a bad reaction to, or are you allergic to:
Tobacco, Alcohol, Drugs
Do you use tobacco? If yes, circle type: smoke chew . How much per day? For how long?
Do you consume alcohol? If yes, approximately how many alcoholic beverages per week?
Do you use any mood altering drugs other than those previously listed?
Blood Pressure
Have you ever received a diagnosis of "high blood pressure"?
What is your normal blood pressure (systolic/diastolic)?
Pulse Today: SpO2 Today: Blood Pressure Today:
Weight and Diet Considerations
Sugar in your diet (circle one): none slight moderate high
____________________________________________
Patient (print name) Patient Signature Date
Dellin R. Bakkum, DDS ____________________________________________ ________________ Doctor Doctor Signature Date DOCTOR’S USE ONLY--------------------------------------------------------------------------------------------------------------------------------------- Comments and Significant Findings:_________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
Dental Management Considerations:_________________________________________________________________________________
______________________________________________________________________________________________________________
Greensboro Medical Associates, PA 1511 Westover Terrace · Suite 201 · Greensboro, NC 27408 Referred here by (check one): _____Self _____Family _____Friend _____Doctor _____Other Health Professional The name of the physician providing your general medical care: Do you have an orthopedic surgeon? ______ Yes ______ No If yes, Name: Describe briefly your present symptoms: Date symptoms
Diplomate, American Board of Oral & Maxillofacial Surgery GENERAL POSTOPERATIVE INSTRUCTIONS We are committed to providing the same quality of care following procedures that began during your initial visit. To that end, please refer to some general postoperative guidelines below, and by all means, CALL at any hour of any day to report any continuing problem. 1. FLUID AND FOOD INTAKE IS