Newdaydentistry.com

Health History
1) Are you in good health? Y N Digitalis, Inderal, Nitroglycerin or other heart Y N
2) Has there been any change in drug? your general health in the past year? Y N Have you ever been advised Not to take a
3) Date of last physical exam:____________ medication? Y N
4) Are you under a physician’s care for Are you taking or have you ever taken
a particular problem? Y N Bisphosphonates for osteoporosis, multiple
5) Have you ever had any serious myeloma, or other cancers(Reclast, Fosomax,
Illnesses, operations, or hospitalizations? Y N Actonel, Bonevia, Aredia, Zometa)? Y N
If yes, describe:_____________________________ List any and all medications you are currently taking,
Including all over the counter medications, diet drugs,
__________________________________________ Vitamins, and minerals:_____________________________
____________________________________________
Do you have or have you ever had: _________________________________________
_____________________________________________
Rheumatic Fever or Rheumatic Heart Disease? Y N _____________________________________________
______________________________________________
Congenital Heart Disease Y N
Cardiovascular Disease(Heart Attack, Heart Y N Are you allergic to or have you had an adverse
Trouble, Heart Murmur, Coronary Artery Disease, reaction to:
Angina, High Blood Pressure, Stroke, Palpitations, Health Surgery, Pacemaker)? Local Anesthesia (Novocain, etc)? Y N
Penicil in or other antibiotics? Y N
Lung Disease(Asthma, Emphysema, COPD, Chronic Sedatives or Barbiturates? Y N
Cough, Bronchitis, Pneumonia, Tuberculosis, Aspirin or Ibuprofen? Y N
Shortness of Breath, Chest Pain) Y N Codeine or other pain killers? Y N
Latex or other Rubber Products? Y N
Seizures, Convulsions, Epilepsy, Fainting, or Y N Metal of any kind? Y N
Dizziness? Chemicals or jewelry (rash or sensitivity) Y N
Food Products? Y N
Bleeding Disorder, Anemia, Bleeding Tendency, Other allergies or reactions? If yes, please list Y N
Blood Transfusion? Do you bruise easily? Y N ____________________________________________
_____________________________________________
Liver Disease(Jaundice, Hepatitis) Y N
Kidney Disease Y N Do you smoke or chew tobacco? Y N
Diabetes Y N How much per day?____________________________
Thyroid Disease(Goiter) Y N Is there a past history of Alcohol or Chemical dependency
Arthritis Y N or Emotional Disorder the may affect the care we provide
Stomach Ulcers or Colitis Y N you? Y N
Glaucoma Y N
Osteoporosis Y N Have you had any serious problems associated
Implants placed anywhere in your body with any previous dental treatment? Y N
(Heart Valve, Pacemaker, Hip or Knee)? Y N
Have you or an immediate family member had any Radiation (X-Ray)treatment for cancer? Y N problem associated with intravenous anesthesia? Y N
Clicking or popping of jaw joint, pain near ear, Do you have any other disease, condition, or difficulty opening mouth, grind or clench teeth? Y N problem not listed above you think the doctor should
know about? Y N
Sinus or Nasal problems? Y N
Any disease, drug or transplant operation that Do you wish to talk to the Doctor privately about has depressed your immune system? Y N anything? Y N
Are you using any of the following: Have you ever had a bone density scan? Y N
For Women Only:
Antibiotics? Y N Are you pregnant, or is there any chance you
Anticoagulants (blood thinners) Y N might be pregnant? Y N
Aspirin or drugs such as Motrin, Aleve, or Are you nursing? Y N
Tylenol? Y N If you are using oral contraceptives, it is important that
High Blood Pressure medications? Y N you understand that antibiotics (and some other
Steroids(Cortisone, Prednisone, Etc) Y N medications) may interfere with the effectiveness or oral
Tranquilizers? Y N contraceptives. Therefore, you will need to use other
Insulin or Oral Anti-Diabetic drugs? Y N forms of birth control for one complete cycle of birth
control pills, after the course of antibiotics or other meds
Is complete. Please consult with your physician for
further guidance.
______________________________________________________ Patient Signature Date

Source: http://www.newdaydentistry.com/userfiles/2077/pdf/Health_history.pdf