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Health histroy form-

HEALTH HISTORY
DIRECTIONS TO THE PATIENT: The following information about your health history is very important for us to provide you with the best possible dental care in the safest manner. Incorrect information may be dangerous to your health. ALL questions must be answered completely and accurately. If you don’t understand a question, or are unsure of the answer, or want to discuss it with the dentist, circle its number or letter. This Health History Questionnaire will become a part of the patient’s dental record and will be considered confidential information.
Name of Your Physician: ________________________________ Office Telephone: ____________________ Address of Your Physician ___________________________________________________________________1. Are you in good health? ……………………………………………….……… Yes 2. Has there been any change in your health in the last year? ………. Yes If yes, explain: __________________________________________________________________________ 3. Have you ever been hospitalized, had a major operation or serious illness? .… Yes If yes, explain: __________________________________________________________________________ 4. Date of your last visit to the doctor: _________________________ Reason for last visit: ________________5. Are you currently receiving treatment or regular medical care by your doctor? . Yes If yes, for what condition(s)? ________________________________________________________________ ________________________________________________________________________________________ 6. Are you taking any of the following medications: a. Antibiotics or sulfa drugs …………………………………………………. Yes b. Anticoagulant (blood thinners) ……………………………………………. Yes No c. Medication for high blood pressure ………………………………………… Yes No Don’t Know d. Cortisone (steroids) ………………………………………………………. Yes No Don’t Know e. Tranquilizers ………………………………………………………………… Yes No Don’t Know f. Antihistamines ….…………………………………………………………. Yes No Don’t Know g. Aspirin ………….…………………………………………………………. Yes No Don’t Know h. Insulin, tolbutamide (Orinase) or other drugs for diabetes …………………. Yes No i. Digitalis, Nitroglycerin or other drugs for heart trouble …………………. Yes j. Birth control pills or other hormones ………………………………………. Yes k. Pain medications such as Advil, Nuprin, Motrin, or Naprosyn ……………. Yes l. Synthroid or other thyroid medication ……………………………………… Yes m. AZT or other drugs for HIV ………………………………………………. Yes n. Others, please list: ______________________________________________________________________ 7. Have you ever taken fen-phen (fenfluramine/phentermine combination)? …. Yes No 8. Have you had any allergic or unusual reactions to any substance or medication? Yes No If yes, specify what substance/medications, and what reactions ____________________________________ HAVE YOU EVER BEEN TREATED BY A DOCTOR FOR (Circle your response and underline any condition(s))
9. Damaged heart valves, artificial heart valves, heart murmur rheumatic fever, rheumatic heart disease ……………………………………………………… Yes No 10. Congenital heart problems …………………………………………………… Yes 11. Heart trouble, heart attack, high blood pressure, stroke? …………………… Yes 12. Do you have pain in your chest upon exertion? ………………………….… Yes No 13. Blood disorders such as anemia or hemophilia? ……………………………. Yes No 14. Breathing problems, emphysema, tuberculosis or other lung problems? …… Yes 15. Asthma, hay fever or hives? ………………………………………………… Yes 16. Stomach or intestinal ulcers? ………………………………………………. Yes No 17. Cancer, x-ray treatments, or chemotherapy? ………………………………. Yes 18. Thyroid trouble? ……………………………………………………………. Yes 19. Diabetes or blood sugar problems? …………………………………………. Yes No 20. Hepatitis, jaundice, or liver disease? ……. Yes 21. Kidney infections, frequent urination, or renal (kidney) dialysis? …….…… Yes 22. Stroke, seizure, fainting spells, numbness or other neurological problems? . Yes 23. Syphilis, gonorrhea, or genital herpes, sexually transmitted disease? ………. Yes 24. AIDS, AIDS-related condition or HIB positive? …………………………… Yes 25. Tumors, or growth? ………………………………………………………. Yes No 26. Arthritis or rheumatism? ………………………………………………….… Yes 27. Phobias, anxieties, depression, psychoses, fears, other mental problems? …. Yes 28. For women, are you pregnant or do you think you may be pregnant? ……… Yes
29. Have you lost weight without dieting or gained weight in recent months? …. Yes No 30. Are there any other problems about your health that you know of? ………… Yes If yes, describe: _________________________________________________________________________ HABITS AND PERSONAL HISTORY:
31. Do you now or have you ever used recreational drugs (besides alcohol or tobacco)?. Yes 32. How many packs cigarettes do you smoke per day? How many years? ………….…____ Packs/Day___ #Yrs
a. If you smoked in the past how many packs per day did you smoke? How many years?____ Packs/Day___#Yrs
b. If you smoke, are you interested in help quitting? …………………………………… Yes
33. How many drinks of beer, wine or liquor do you have per day? ……………………. ____ Drinks per Day DENTAL HISTORY:
34. How often do you have your teeth cleaned/dental check-ups? ______________________________________35. What do you do each day to take care of your teeth and gums? _____________________________________36. Have you ever had any specialized dental treatment? …………………….… Yes No Don’t Know37. Have you ever had an unusual reaction to a dental procedure or anesthetic? … Yes No Don’t Know38. Have you ever experienced bleeding/complications following dental treatment? Yes No Don’t Know If yes, explain: ___________________________________________________________________________39. Have you had any injury to your teeth, jaws or face? …………………………. Yes No Don’t Know CURRENT DENTAL CONCERNS:
40. What is your major dental concern? ___________________________________________________________41. Are you unhappy with the appearance of your teeth? . Yes 42. Do your gums bleed when you brush your teeth or when you eat? ………… Yes 43. Do you clench or grind your teeth? …………………………………………. Yes 44. Does food or dental floss catch between your teeth? ………………………. Yes 45. Are some of your teeth becoming loose? …………………………………… Yes 46. Are there spaces between your teeth now where there were none before? …. Yes 47. Are your teeth sensitive to hot, cold, or pressure? …………………………. Yes 48. Do any of your teeth ache? …………………………………………………. Yes 49. Do you experience pain or clicking in your jaw joints? ……………………. Yes 50. Are there any sores or growths in your mouth? ……………………………. Yes 51. Are you worried about receiving dental treatment? ………………………… Yes SIGNATURE OF PATIENT: I understand the need for these questions to be answered truthfully. To the best of
my knowledge, the answers I have given are accurate. I also understand it is very important to report any changes
in my medical or dental status to the dentist at the earliest possible time, and I agree to do so. I give my permission
to the dentist to obtain from any physician or dentist, any additional information regarding my medical history
needed to provide me to the best dental treatment possible.
PERSON COMPLETING FORM: Signature: ______________________________ Date:________________
If other than patient, indicate relationship: __________________________________________________________ MEDICAL HISTORY REVIEW
SIGNATURE, ATTENDING DENTIST: ___________________________ DDS, MS Date: _______________
______________________________________________________________________________________________________________ ______________________________________________________________________________________________________________ ______________________________________________________________________________________________________________

Source: http://www.gumsandimplants.org/Site_2/Forms_files/Health%20History.pdf

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