Health history

HEALTH HIS TORY
Na me ______________________________________________ Date _____________________________ Date of last health care e xa m: ________________What was this exa m for?_________________________ Have you been hospitalized in the last 5 years? (Please circle ) If yes, reason:__________________________________________________________________________ Are you currently receiving care? No Yes If yes, nature of care : _________________________ Please list all the names and phone numbers of the physicians who are currently providing you care: 1. ____________________________________________________________________ 2. ____________________________________________________________________ 3. ____________________________________________________________________ 4. ____________________________________________________________________ For the following questions circle yes or no. Your answers are for our records only and will be confidential. Please note that during your initial visit you will be ask ed some questions about your response. Our team may ask additional questions concerning your health. Anemia or Blood Disorder? Arthritis, Rheumat ism or other infla mmatory disease? Emphysema or other Respiratory/ Lung Illnesses Abnormal Heart or Previous Bacteria l Endocardit is Heart Valve (artificia l) or Heart Transplant Heart Disease, Heart Attack, Heart Surgery Are you taking any of these medications? Pre-medication before dental treat ment? Tagamet® (c imetid ine) or Prilosec® (omepra zole )? Card ize m® (d ilt ia ze m) or Ca lan, Isoptin® Diflucan® (fluconazole) or Sporono x® Have you been treated with Bisphosphonate drugs (Fosama x®, Ared ia®, Zo meta®, Actonel®, Boniva®)? If so, when did the treatment begin? When did the treatment end? Have you ever taken any prescription drugs such as fen-phen for weight loss? Do you consume grapefru it ju ice, grapefruits or grapefru it e xtract? Please list any medicat ions you are currently taking and dosages: 1. _________________________________________ 3. _________________________________________ 5. _________________________________________ 7. _________________________________________ Please list any dietary or herbal supplements you are taking, and for what purpose: 1. _________________________________________ 3. _________________________________________ 5. _________________________________________ Copyright NPPLLC 2008, All Rights Reserved If no, a re you planning a pregnancy in the near future? Abnormal Blood Pressure? (Please circle ) Have you ever received a diagnosis of “high blood pressure”? What is your norma l b lood pressure? Are you allerg ic or have you had a reaction to: a. Local anesthetics ………………………………………………………. b. Penicillin o r other antibiotics …………………………………………… c. Aspirin, Ibuprofen or Ty lenol ….……………………………………… d. Codeine, Valiu m or other sedatives…………………………………… Other (p lease specify)____________________________________________________ Tobacco, Alcohol, Drugs Do you use tobacco? If yes, circ le type: s moke chew Ho w much per day? For how long? Do you consume alcohol? If yes, approximate ly how many a lcoholic beverages per week? Do you use any mood altering drugs other than those previously listed? Sugar in your diet (circle one): none slight moderate high DOCTOR’S USE ONLY Co mments on patient interview concerning medica l h istory: ____________________________________________________________________________________________________________________________________________________________________________ ____________________________ Significant findings fro m questionnaire or ora l interview: __________________________________________________________________________________________________ __________________________________________________________________________ ____________________________ Dental manage ment considerations: ____________________________________________________________________________________________________________________________________________________________________________ ____________________________ I understand the above information is necessary to provide me with dental care in a safe and efficient manner. I have answered all questions to the best of my k nowledge. Should further information be needed, you have my permission to ask the respective health care provider or agency, who may release such information to you. I will notify the doctor of change in my health and medication. _______________________________ ____________________________ __________________ ____________________________ __________________ Copyright NPPLLC 2008, All Rights Reserved

Source: http://www.chesterdentist.com/Health_History.pdf