Health history (sample a)


Answer all questions by circling Yes (Y) or No (N)
All responses are kept confidential
Are you taking or have you ever taken Bisphospho-
nates for osteoporosis, multiple myeloma or other cancers (Reclast, Fosamax, Actonel, Boniva, 4. Are you now under a physician’s care for Have you ever been advised not to take a medication? 5. Have you ever had any serious illnesses,
K. Please list any and all medications taken, including operations or hospitalizations? If so, describe:. Y N prescription medications, diet drugs, over-the-counter medications, herbal or holistic remedies, vitamins or 6. DO YOU HAVE OR HAVE YOU EVER HAD:
A. Rheumatic Fever or Rheumatic Heart Disease? . Y N 8. ARE YOU ALLERGIC TO OR HAVE YOU HAD AN
C. Cardiovascular Disease (Heart Attack, Heart ADVERSE REACTION TO:
Trouble, Heart Murmur, Coronary Artery Disease, A. Local Anesthesia (Novacain, etc.)? . Y N Angina, High Blood Pressure, Stroke, Palpitations, B. Penicillin or other antibiotics? . Y N D. Lung Disease (Asthma, Emphysema, COPD, Chronic Cough, Bronchitis, Pneumonia, Tuberculosis, E. Seizures, Convulsions, Epilepsy, Fainting or H. Chemicals or jewelry (rash or sensitivity)? . Y N F. Bleeding Disorder, Anemia, Bleeding Tendency, Other allergies or reactions? Please list. Y N Blood Transfusion? Do you bruise easily? . Y N G. Liver Disease (Jaundice, Hepatitis)? . Y N 10. Is there any past history of Alcohol or Chemical Dependency or Emotional Disorder that may affect 11. Have you had any serious problems associated with O. Implants placed anywhere in your body 12. Have you or an immediate family member had any (Heart Valve, Pacemaker, Hip, Knee)? . Y N problem associated with intravenous anesthesia? . Y N P. Radiation (X-ray) treatment for Cancer? . Y N 13. Do you have any other disease, condition or Q. Clicking or popping of jaw joint, pain near ear, problem not listed above that you think the doctor difficulty opening mouth, grind or clench teeth? . Y N 14. Do you wish to talk to the doctor privately S. Any disease, drug or transplant operation that has depressed your immune system? . Y N 15. Have you ever had a bone density scan? . Y N 7. ARE YOU USING ANY OF THE FOLLOWING:
A. Are you Pregnant, or is there any chance
B. Anticoagulants (Blood Thinners)? . Y N C. Aspirin or drugs such as Motrin, Aleve, Ibuprofen? . Y N D. High Blood Pressure medications? . Y N C. If you are using Oral Contraceptives, it is important
E. Steroids (Cortisone, Prednisone, etc.)? . Y N that you understand that antibiotics (and some other medications) may interfere with the effectiveness of oral G. Insulin or Oral Anti-Diabetic drugs? . Y N contraceptives. Therefore, you will need to use H. Digitalis, Inderal, Nitroglycerin or other heart drug? Y N 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. I understand the importance of a truthful and complete Health History to assist my dentist in providing the best care possible. I
have had the opportunity to discuss my Health History with my dentist.

Signature of Person Completing Health History Chief Dental Complaint: ________________________________________________________________________________________ ____________________________________________________________________________________________________________
I have read and understand the above. Any questions I had about this form have been answered and I understand the answers. I
understand it is my responsibility to fill out the form correctly and completely.
Date: _____________ Patient’s Signature: _______________________________________

Comments on patient interview concerning medical history: _____________________________________________________________
_____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ Significant findings from questions or oral interview: ___________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ Dental Management Considerations: _______________________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ Dentist’s Signature: _______________________________________


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