Microsoft word - health information and history form_04-30-07.doc
Health Information and History Today’s Date
Date of Birth
If you are completing this form for another person: Your name:
: (If not listed above)
Other Physicians & Specialists
1. With in the last 3 years, have you been hospitalized or had surgery?
2. Have you ever been instructed to take ANY medications or
take ANY special precautions before any dental appointments*?
3. Are you taking ANY drugs, medications, or treatments at this time?
(If you brought a complete written list with you, give that to the receptionist instead) Prescribed:
Over-the-counter (OTC) medications (such as Aspirin, Advil, allergy medication, sleeping aids, etc):
Vitamins, natural or herbal preparations and/or dietary supplements:
Are you having or have you ever had radiation or chemotherapy treatments*
Name of facility performing the treatment :
4. Are you taking or have you ever taken / been treated with a Bisphosphonate (Fosamax)?
5. Are you allergic to or have you ever experienced an unusual reaction to:
6. Are you allergic to or have you ever had any reaction to any of the following drugs?
Penicillin (or related drugs)
Aspirin / Ibuprofen (Advil, Motrin, Nuprin)
7. Have you had an allergic reaction or unusual response to
ANY other medications, drugs, pills, or treatments?
Continued on next page…
Health Information and History (continued)
8. Do you have, or have you ever had, any of the following?
(Please check Yes or No for each question)
Tuberculosis, emphysema or lung disorder
Rheumatic heart disease / rheumatic fever
Heart valve(s) damage / Mitral valve prolapse
Ulcers, acid reflux, or stomach problems
(Lupus, HIV, AIDS, radiation immune problem, etc.)
An active sexually transmitted disease (STD)
Been treated for any psychiatric condition
Excessive bleeding from any cut or incident
Any artificial joint, joint surgery, or prosthesis
Hepatitis, jaundice, or other liver problems
Are you taking hormone replacement therapy
9. Do you have any other conditions, diseases, or medical problems, or is there ANY other
information that you would like us to know about, or that we should be made aware of?
If Yes, please explain:
CONSENT — To the best of my knowledge, all of the preceding information is correct and if there is ever any change in health, or medications, this practice wil be informed of the changes without fail. I also consent to al ow this practice to contact any healthcare provider(s) and to have the patient’s health information released to aid in care and treatment. I also hereby consent to al ow diagnosis, proper health care and treatment to be performed by this practice for the above named individual until further notice.
I understand there are no guarantees or warranties in health or dental care.
(Parent or guardian, if patient is a minor)
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