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: MM slash DD slash YYYY 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: Rheumatic Fever or Rheumatic Heart Disease? Congenital Heart Disease? Cardiovascular Disease (Heart Attack, Heart Trouble, Heart Murmur, Coronary Artery Disease, Angina, High Blood Pressure, Stroke, Palpitations, Heart Surgery, Pacemaker?) Lung Disease (Asthma, Emphysema, Chronic Cough, Bronchitis, Pneumonia, Tuberculosis, Shortness of Breath, Chest Pain, Severe Coughing?) Seizures, Convulsions, Epilepsy, Fainting or Dizziness? Do you bruise easily? (Bleeding Disorder, Anemia, Bleeding Tendency, Blood Transfusion?) Liver Disease? Kidney Disease? Diabetes? Thyroid Disease (Goiter)? Arthritis? Stomach Ulcers or Colitis? Glaucoma? Implants placed anywhere in your body? (Heart Valve, Pacemaker, Hip, Knee, Shoulder) Radiation (X-ray) treatment for Cancer? Clicking or popping of jaw joint, pain near ear, difficulty opening mouth, grind or clench teeth? Sinus or Nasal Problems? 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: MM slash DD slash YYYY Are you using any of the following: Antibiotics? Antidepressants? Anticoagulants (Blood Thinners, i.e. warfarin?) Aspirin or drugs such as Motrin, Aleve, Ibuprofen? High Blood Pressure medications? Steroids? (Cortisone, etc.) Tranquilizers? Insulin or Anti-Diabetic drugs? Digitalis, Inderal, Nitroglycerin or other heart drug? Are you taking or have you ever taken Bisphosphonates? (Fosamax, or Actonel for osteoporosis, or Chemotherapy for multiple myeloma, etc.) 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 ONLYAre you Pregnant, or is there a chance you might be Pregnant? Yes No Are you nursing? Yes No NOTElf 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.ContactName of person we can contact in case of an Emergency: First Last PhoneAlt. PhoneI 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
