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



Who Was this Jesus? John 18:1 - 19:37 Good Friday, April 22, 2011 St. Alban’s, Hickory, NC Our Lenten journey, our Holy Week journey is almost over. This week juxtaposes the extremes of Jesus’ earthly ministry and the human reaction to it: waving of palms and welcome cries of Hosanna, followed by cries to crucify him and rejection and denial, contrasted with Jesus’ steadily, purposefully

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