Health History Form Patient Name:*Soc. Sec. No.:*Email Birth Date:* MM slash DD slash YYYY Name of M.D.:*Person Responsible for Account:Name:Relationship to patient:Address: Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code I. CLICK ON APPROPRIATE ANSWER (leave Blank if you do not understand question):1. Is your health good? Yes No 2. Has there been a change in your health within the last year? Yes No Please describe:3. Have you been hospitalized or had a serious illness in the last three years? Yes No Why?4. Are you being treated by a physician now? Yes No For what?Date of last medical exam:Date of last dental exam:5. Have you had problems with prior dental treatment? Yes No Please explain:6. Are you in pain now? Yes No Please describe:II. HAVE YOU EXPERIENCED:7. Chest Pain (angina)? Yes No 8. Swollen ankles? Yes No 9. Shortness of breath? Yes No 10. Recent weight loss, fever, night sweats? Yes No 11. Persistent cough, coughing up blood? Yes No 12. Bleeding problems, bruising easily? Yes No 13. Sinus problems? Yes No 14. Difficulty swallowing? Yes No 15. Diarrhea, constipation, blood in stools? Yes No 16. Frequent vomiting, nausea? Yes No 17. Difficulty urinating, blood in urine? Yes No 18. Dizziness? Yes No 19. Ringing in ears? Yes No 20. Headaches? Yes No 21. Fainting spells? Yes No 22. Blurred vision? Yes No 23. Seizures? Yes No 24. Excessive thirst? Yes No 25. Frequent urination? Yes No 26. Dry mouth? Yes No 27. Jaundice? Yes No 28. Joint pain, stiffness? Yes No III. DO YOU HAVE OR HAVE YOU HAD:29. Heart disease? Yes No Please describe:30. Heart attack, heart defects? Yes No Please describe, provide year and cardiologist's name:31. Heart murmurs or Rheumatic Fever? Yes No 32. Osteonecrosis? Yes No 33. Stroke, hardening of arteries? Yes No Please describe, provide year:34. High blood pressure? Yes No 35. Asthma, TB, emphysema, other lung diseases? Yes No Please describe:36. Hepatitis, other liver disease? Yes No Please describe:37. Stomach problems, ulcers? Yes No 38. Allergies to: drugs, foods, medications, latex? Yes No Please describe: 39. Family history of diabetes, heart problems, tumors? Yes No Please describe:40. AIDS? Yes No 41. Tumors, cancer? Yes No Please describe, provide year and oncologist's name: 42. Arthritis, rheumatism? Yes No 43. Eye disease? Yes No 44. Skin diseases? Yes No 45. Anemia? Yes No 46. VD (syphilis or gonorrhea)? Yes No 47. Herpes? Yes No 48. Kidney, bladder disease? Yes No 49. Thyroid, adrenal disease? Yes No 50. Diabetes? Yes No IV. DO YOU HAVE OR HAVE YOU HAD:51. Psychiatric care? Yes No Please describe type, meds provided, provide year and therapist's name:52. Radiation treatments? Yes No Please describe, provide year and oncologist's name: 53. Chemotherapy? Yes No Please describe, provide year and oncologist's name: 54. Prosthetic heart valve? Yes No Please describe, provide year and cardiologist's name; premed required?55. Artificial joint? Yes No Please describe, provide year and surgeon's name and phone number; premed required?56. Hospitalization? Yes No Please describe, provide year:57. Blood transfusions? Yes No 58. Surgeries? Yes No Please describe, provide year and surgeon's name and phone number: 59. Pacemaker? Yes No Please describe, provide year and cardiologist's name; premed required?60. Contact lenses? Yes No V. ARE YOU TAKING:61. Recreational drugs? Yes No Please list: 62. Drugs, medications, over-the-counter medicines (including Aspirin), natural/homeopathic remedies? Yes No Please list: 63. Tobacco in any form? Yes No Please list type, quantity smoked per day & number of years:64. Alcohol? Yes No Please list type & number of beverages per day:65. Herbals? Yes No Please list: VI. WOMEN ONLY:66. Are you or could you be pregnant or nursing? Yes No 67. Taking birth control pills? Yes No VII. ALL PATIENTS:68. Have you ever taken fen-phen? Yes No 69. Do you have or have you had any other disease or medical problems NOT listed on this form? Yes No If so, please explain:70. Fosamax or other bisphosphonates? Yes No To the best of my knowledge, I have answered every question completely and accurately. I will inform my dentist of any change in my health and/or medication. I have received and understand the “Notice of Privacy Practices” dated September 16, 2016. I have received a copy of the “Dental Material Fact Sheet” published May 2004 as required by law.Patient/Parent/Guardian signature:*The signer must be 18 years or older.Date* MM slash DD slash YYYY Children under 18 need a parent signature. If under 18, please print name & relationship below:Name:Relationship with patient:This field is hidden when viewing the formDoctor’s signature:This field is hidden when viewing the formDate:This field is hidden when viewing the formHygienist’s signature:This field is hidden when viewing the formDate: Δ
