Health history

HEALTH HISTORY
Name _________________________________________________________ Date _____________________________ Date of last health care exam: ___________________________What was this exam for? ________________________ Have you been hospitalized in the last 5 years? (Please circle) If yes, reason:_____________________________________________________________________________________ Are you currently receiving care or have had a physical within the past 2 years? 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. ________________________________________________________________________________________ Arthritis, Rheumatism or other inflammatory disease Emphysema or other Respiratory/Lung Illnesses Abnormal Heart or Previous Bacterial Endocarditis Heart Valve (artificial) or Heart Transplant Heart Disease, Heart Attack, Heart Surgery
Other conditions or surgeries not listed above?
Please explain:____________________________________________________________________________________
Do you need to take an antibiotic before dental care? No / Yes
SPECIFIC MEDICATIONS
Tagamet® (cimetidine) or Prilosec® (omeprazole) Cardizem® (diltiazem) or Calan, Isoptin® (Verapamil) Diflucan® (fluconazole) or Sporonox® (itraconazole) Have you been treated with Bisphosphonate drugs (Fosamax®, Aredia®, Zometa®, Actonel®, Boniva®)? If so, when did the treatment begin? When did the treatment end? Do you consume grapefruit juice, grapefruits or grapefruit extract? Please list any medications you are currently taking and dosages: 2._____________________________________ 3._____________________________________ 4._____________________________________ Please list any dietary or herbal supplements you are taking, and for what purpose: 2._____________________________________ 3._____________________________________ If no, are you planning a pregnancy in the near future? No Are you allergic or have you had a reaction to: a. Local anesthetics ………………………………………………….No b. Penicillin or other antibiotics ……………………………………. No Aspirin, Ibuprofen or Tylenol ….………………………………… No d. Codeine, Valium or other sedatives…………………………… No e. Latex ………………………………………………………………. No Yes f. Metals ……………………………………………………………. No Yes g. Other (please specify)____________________________________________________ Do you use tobacco? If yes, smoke or chew How much per day? For how long? Do you consume alcohol? If yes, approximately how many alcoholic beverages per week? Do you use any mood altering drugs other than those previously listed? 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 knowledge. 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 changes in my health and medication. __________________________________ ____________________________________ ______________________ Patient / Legal Guardian (Print Name)
DOCTOR’S USE ONLY
REVIEWED BY:
Comments on patient interview concerning medical history: __________________________________________________________________ Significant findings from questionnaire or oral interview __________________________________________________________________ Dental management considerations: ________________________________________________________________________

Source: http://www.crosstimbersdental.com/images/Health_History_pdf.pdf