Patient First Name:
MI:
Last Name:
Birth Date:
Sex:
MALE
FEMALE
GENERAL HEALTH QUESTIONS
Have you had any serious illness, operations or hospitalizations?
YES
NO
Are you under a physician's care at this time?
YES
NO
Name of physician:
Address of physician:
Phone # of physician:
Do you have or did you ever have any of the following?
Cardiovascular Health
High Blood Pressure
YES
NO
Angina or heart attack
YES
NO
Chest pain on physical exertion
YES
NO
Coronary artery blockage or treatment (bypass, stent, etc.)
YES
NO
Heart valve problem or replacement
YES
NO
Heart murmur
YES
NO
Heart disease, problem or treatment
YES
NO
Rheumatic fever
YES
NO
Past use of Fen-Phen
YES
NO
Irregular heart beat or pacemaker
YES
NO
Difficulty breathing when lying down
YES
NO
Stroke
YES
NO
Low blood pressure
YES
NO
Respiratory Health
Asthma
YES
NO
Emphysema or respiratory problems
YES
NO
Chronic sinus problems
YES
NO
Tuberculosis or persistent cough
YES
NO
Endocrine/Blood/Immune Health
Diabetes
YES
NO
Frequent thirst or frequent urination
YES
NO
Thyroid problema
YES
NO
Abnormal bleeding, brulse easily
YES
NO
Hemophillia
YES
NO
Anemia/blood disease
YES
NO
Cancer
YES
NO
Radiation therapy/chemotherapy
YES
NO
HIV infection/AIDS
YES
NO
Cold sores/canker sores
YES
NO
Organ transplant
YES
NO
Blood transfusion
YES
NO
Muscular-Skeletal/CNS/Mental Health
Joint replacement
YES
NO
Arthtritis
YES
NO
Osteoporosis
YES
NO
Fainting spells or dizziness
YES
NO
Selzures
YES
NO
Numbness or muscle weakness
YES
NO
Multiple sclerosis
YES
NO
Mental retardation
YES
NO
Dementia/Alzheimer's disease
YES
NO
Anxiety/Nervousness
YES
NO
Mental health treatment
YES
NO
Gastro-Intestinal/Genito-Urinary Health
Hepatitis (A,B,C or other)
YES
NO
Liver disease
YES
NO
Kidney disease/dialysis
YES
NO
Stomach trouble/ulcers
YES
NO
Sexually transmitted disease
YES
NO
Medication Allergies and Other Allergies
Penicillin or other antibiotics
YES
NO
Sulfa drugs
YES
NO
Dental antesthetic
YES
NO
Aspirin
YES
NO
Codeine/narcotics
YES
NO
Iodine
YES
NO
Latex products
YES
NO
Metals/nickela/jewelry
YES
NO
Other:
YES
NO
Females Only
Are you pregnant?
YES
NO
Are you nursing now?
YES
NO
Do you take birth control pills?
YES
NO
Medications
Are you taking any prescription medications, over the counter medications or herbal medicines?
YES
NO
If so, please list them and the dose taken:
Do you or have you used biphosphonate medication (Fosomax, Actonel, Boniva, Skelld, Didronel, Aredia, Zometa, Bonefos)?
YES
NO
Social
Do you use tobacco?
YES
NO
Quantity
Per Day
Do you use alcohol?
YES
NO
Quantity
Per Day
Per Week
Do you use recreational drugs?
YES
NO
Quantity
Per Day
Do you have any other medical conditions not already listed above?
YES
NO
Please list:
I hereby certify that I have read the foregoing and filled out this questionnaire completely. I have advised you of all medical problems of which I am aware. I further certify that I, the unsigned, consent to the performing of x-rays and examinations.
Signature of PATIENT or GUARDIAN
Date:
Signature of DENTIST
ID#
Date:
UPDATE
Have there been any changes in your medical history, including any medications that you take, since you last completed this form?
YES
NO
Signature of PATIENT or GUARDIAN
Date:
Signature of DENTIST
Date: