Health Information and History
Date of Birth:
If you are completing this form for another person:
(If not listed above)
City & State:
Date of last physical examination:
Date of last blood test / work up:
Other Physicians & Specialists:
City & State:
City & State:
1. Within the last 3 years, have you been hospitalized or had surgery?
If yes, please give reasons and dates:
Have you ever been instructed to take ANY medications or take ANY special precautions before and dental appointments?
If yes, please explain:
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)
Over-the-counter (OTC) medications (such as Aspririn, Advil, allergy medication, sleeping aids, etc):
Vitamins, natural or herbal preperations and / or dietary supplements:
Are you having or have you ever had radiation or chemotherapy treatments?
If Yes, for how long?
Name or facility performing the treatment:
4. Are you taking or have you taken / been treated with a Bisphosphonate (Fosamax)?
5. Are you allergic to or have you ever experienced an unusual reaction to:
Metals or jewelry
6. Are you allergic to or have you ever had any reaction to any of the following drugs?
(or realted drugs)
Aspirin / Ibuprofen
(Advil, Motrin, Nuprin)
(Celebrex, Vioxx, Anaprox)
7. Have you had an allergic reaction or unusal repsonse to ANY other medications, drugs, or treatments?
If Yes, please list:
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)
Congenital heart defects
Angina or chest pains
Hay fever, skin or food allergies or allergies in general
Congestive heart failure
Turberculosis, emphysema or lung disorder
Coronary artery disease
A sore or wound that bleeds easily or does not heal
If Yes, type & date:
A thyroid problem or disease
If Yes, date:
Glaucoma or any eye diseases
Rheumatic heart disease / rheumatic fever
Epilepsy or other seizure disorder
Any kidney problems
Heart valve(s) damage / Mitral valve prolapse
Ulcers, acid reflux, or stomach problems
Artificial heart valve
A compromised immune system
(Lupus, HIV, AIDS, radiation immune problem, etc.)
Stroke or CVA
An active sexually transmitted disease (STD)
High blood pressure
Any mental health issues
Low blood pressure
Been treated for any psychiatric condition
Hemophilia or bleeding disorder
Excessive bleeding from any cut or incident
Are you pregnant
Diabetes or blood sugar problems
If Yes, what is your due date:
Any artifical joint, joint surgery, or prosthesis
Do you think you might be pregnant
If Yes, what joint or area:
Are you presently nursing
When was the operation done:
Are you using birth control medication
Hepatitis, jaundice, or other liver problems
Are you taking hormone replacement therapy
Any form of cancer
An organ transplant
Do you have any other conditions, disease, 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 will be informed of the changes without fail. I also consent to allow 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 allow diagnosis, proper health care and treatment to be performed by this practice for the above named individual until further notice. I understand that there are no guarantees or warranties in health or dental care.
(Parent or guardian, if patient is minor)
Patient Validation: Please Enter Full Name