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Macoupin county maple street dental clinic

Macoupin County Maple Street Dental Clinic
HEALTH HISTORY

Patient’s Name_________________________________________ Today’s Date_______________________

Street Address_________________________________________ Birthdate__________________________
City__________________ State________ Zip_____________
Sex (circle) M / F Date of last dental exam___________________
Phone number ( ) Work/other number ( )_______________________________
Physician’s Name__________________________ Address________________________________________
Please answer all questions by circling Yes (Y) or No (N). All responses are kept confidential.
1. Has there been any change in your
6. Are you allergic or had an adverse reaction to:
2. Have you ever had any illness, operations,
If yes, please describe_________________________ _____________________________________________
_____________________________________________
_____________________________________________
h. Please list any other allergies/reactions. _____________________________________________ 3. Are you being treated by a physician
_____________________________________________ _____________________________________________ 7. Are you using any of the following:
5. Do you currently have or have ever had:
a. Rheumatic fever/rheumatic heart disease? Y N
Circle all that apply: heart disease,
heart murmur, heart attack, coronary artery disease, angina, high blood pressure, stroke, i. Oral bisphosphates (bone hardening meds)? Y N
j. IV bisphosphates (bone hardening meds)? Circle all that apply: asthma, tuberculosis, chest
pain, severe coughing, bronchitis, pneumonia e. Seizures, epilepsy, fainting, dizziness? 8. Do you smoke or chew tobacco?
g. Liver disease (jaundice, Hepatitis)? 9. Do you have a past history of alcohol
or chemical dependency?
10. Have you had any serious problems
Glaucoma? Y N
11. Please list current medications. Include
prescriptions, over-the-counter, vitamins, and herbal
12. For Women Only
remedies.
Medication
Due Date______________________
_____________________________________________
_____________________________________________
If you are using oral contraceptives, it is important that you
understand that antibiotics and some other medications may
_____________________________________________
interfere with the effectiveness of oral contraceptives. _____________________________________________
Therefore, you will need to use mechanical forms of birth _____________________________________________
control for one complete cycle of birth control pills after the _____________________________________________
course of antibiotics or other medication is completed. Please _____________________________________________
consult with your physician for further guidance. _____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________

Please list any medical or dental problems or concerns that were not covered in above questions.
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
I understand the importance of a truthful health history to assist the dental staff in providing the best
care possible. I have had the opportunity to discuss my health history with my doctor.
Date___________ Patient/Guardian Signature__________________________ Dentist’s initials__________
Medical Update: I have read and updated my health history dated_________________ and confirm that

it adequately states past and present conditions.

Date___________ Exceptions/changes________________________________________________
___________________________________Signature

Date_____________

Date___________ Exceptions/changes________________________________________________
___________________________________Signature

Date_____________

Date___________ Exceptions/changes________________________________________________

__________________________________ Signature and Date___________

Revised 11/2011

Source: http://www.mcphd.net/cms/uploads/file/health%20history.pdf

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