Health History Questionnaire – Indianapolis Dentist

Are you in good health?

Yes
No

Has there been any change in your general health in the past year?

Yes
No

Date of last physical exam:

Have you ever had any serious illnesses, operations or hospitalizations?

Yes
No

Please Describe:

Has your physician or surgeon ever recommended pre-medication prior to dental treatment?

Yes
No

Height

Weight

Do you or have you ever had the following:

Most recent HbA1C: (%)

Any disease, drug or transplant operation that has depressed your immune system?

Yes
No

Problems with mental health?

Yes
No

Problems with neurological disease?

Yes
No

Have you ever tested positive for HIV, Hepatitis B or C?

Yes
No

Most current lab values:

Date of most current lab values:

Are you using any of the following:

Please list any and all medications taken, including prescription medications, over the counter medications, herbal or holistic remedies, vitamins and/or minerals:

Are you allergic to or have you ever had an adverse reaction to:

Local Anesthesia (Novocain, etc.?)
Penicillin or other antibiotics?
Sedatives, Barbiturates?
Aspirin or Ibuprofen?
Codeine or other pain killers?
Latex or other rubber products?

Other allergies or reactions? Please List:

Do you smoke or chew Tobacco?

Yes
No

Are there any past history events of Alcohol or Chemical Dependency or Emotional Disorders that may affect the care we care for you? (marijuana, street drugs)

Yes
No

Have you had any serious problems associated any previous dental treatment? (excessive bleeding)

Yes
No

Have you or an immediate family member had any problem associated intravenous anesthesia?

Yes
No

Do you have any other disease, condition or problem not listed above that you think the doctor should know about?

Yes
No

Do you wish to talk to the doctor privately?

Yes
No

FOR WOMEN ONLY

Are you Pregnant, or is there a chance you might be Pregnant?

Yes
No

Are you nursing?

Yes
No

NOTE

lf 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 alternative 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.

Contact

Name of person we can contact in case of an Emergency:

First Last

Phone

Alt. Phone

I understand the importance of a truthful Health History to assist the doctor in providing the best care possible. I have had the opportunity to discuss my Health History with my doctor.*

I Agree

ESIGNATURE