Health_history_form_2012

BLUE DIAMOND DENTAL, P.A. – Vincent J. Daniels, DMD
Health Information and History
Today’s Date: ______________

Patient’s Name: ________________________________________Date of Birth: ______________
If you are completing this form for another person:
Your name: __________________________ Phone: ________________ Relationship: ________________

Emergency Contact: (If not listed above)
Name: ______________________________ Phone: ________________ Relationship: ________________

Primary Physician: _________________ Phone: _________________ City & State: ________________
Date of last physical examination: ________________ Date of last blood test/work up:_________________

Other Physicians & Specialists
Name: ____________________ Specialty: __________ Phone: ___________ City & State: ____________
Name: ____________________ Specialty: __________ Phone: ___________ City & State: ____________

1. With in the last 3 years, have you been hospitalized or had surgery? Yes No
If Yes, please give reasons and dates:________________________________________________

2. Have you ever been instructed to take ANY medications or
take ANY special precautions before any dental appointments*? Yes No
If Yes, please explain: _______________________________________________________________

3. Are you taking ANY drugs, medications, or treatments at this time? Yes No
(If you brought a complete written list with you, give that to the receptionist instead)
Prescribed: ________________________________________________________
________________________________________________________________
Over-the-counter (OTC) medications (such as Aspirin, Advil, al ergy medication, sleeping aids, etc):
________________________________________________________________
Vitamins, natural or herbal preparations and/or dietary supplements:
________________________________________________________________
Are you having or have you ever had radiation or chemotherapy treatments*? Yes No
If Yes, for how long?______________ Name of facility performing the treatment :_______________

4. Are you taking or have you ever taken/been treated with a Bisphosphonate (Fosamax)? Yes No
5. Are you allergic to or have you ever experienced an unusual reaction to:
___Latex
_____NONE
___Nitrous oxide (laughing gas) ___General anesthesia
6. Are you allergic to or have you ever had any reaction to any of the following drugs?
___Penicillin (or related drugs)
___Aspirin / Ibuprofen (Advil, Motrin, Nuprin)
7. Have you had an allergic reaction or unusual response to
ANY other medications, drugs, pills, or treatments? Yes No

If Yes, please list :___________________________________________________________
BLUE DIAMOND DENTAL, P.A. – Vincent J. Daniels, DMD
Health Information and History (continued)
Patient’s Name: ______________________________
8. Do you have, or have you ever had, any of the following? (Please check Yes or No for each question)
___ ___ Hay fever, skin or food al ergies ___ ___ Tuberculosis, emphysema or lung disorder If Yes, type & date ____________________ ___ ___ A sore or wound that bleeds easily ___ ___ Rheumatic heart disease/ Rheumatic fever ___ ___ Heart valve(s) damage/ Mitral valve prolapse ___ ___ Epilepsy or other seizure disorder ___ ___ Ulcers, acid reflux, or stomach problems (Lupus, HIV, AIDS, radiation immune problem, etc.) ___ ___ An active sexual y transmitted disease (STD) ___ ___ Been treated for any psychiatric condition ___ ___ Excessive bleeding from any cut or incident ___ ___ Diabetes or blood sugar problems ___ ___ An organ transplant
___ ___ Any artificial joint, joint surgery, or prosthesis Women Only: Yes No
If Yes, what join t or area: ______________ If Yes, what is your due date: ____________ ___ ___ Hepatitis, jaundice, or other liver problems ___ ___ Do you think you might be pregnant ___ ___ Are you using birth control medication ___ ___ Are you taking hormone replacement therapy
9. Do you have any other conditions, diseases, 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? Yes No
If Yes, please explain: ____________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
CONSENT — To the best of my knowledge, al 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 al ow 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 al ow diagnosis, proper health care and
treatment to be performed by this practice for the above named individual until further notice.
I understand there are no guarantees or warranties in health or dental care.
Signature__________________________________________ Date ___________________
(Parent or guardian, if patient is a minor)

Source: http://www.bluediamonddental.com/pdf/health_history_form_2012.pdf