Health history (sample a)

HEALTH HISTORY

Answer all questions by circling Yes (Y) or No (N)
All responses are kept confidential
G. Insulin or Oral Anti-Diabetic drugs? . Y N H. Digitalis, Inderal, Nitroglycerin or other heart drug? Y N Are you taking or have you ever taken Bisphospho-
nates for osteoporosis, multiple myeloma or other 4. Are you now under a physician’s care for cancers (Fosamax, Actonel, Boniva, Aredia, 5. Have you ever had any serious illnesses,
Please list any and all medications taken, including operations or hospitalizations? If so, describe: . Y N prescription medications, diet drugs, over-the-counter mediations, herbal or holistic remedies, vitamins or 7. DO YOU HAVE OR HAVE YOU EVER HAD:
A. Rheumatic Fever or Rheumatic Heart Disease? . Y N 9. ARE YOU ALLERGIC TO OR HAVE YOU HAD AN
ADVERSE REACTION TO:
C. Cardiovascular Disease (Heart Attack, Heart A. Local Anesthesia (Novocain, etc.)? . Y N Trouble, Heart Murmur, Coronary Artery Disease, B. Penicillin or other antibiotics? . Y N Angina, High Blood Pressure, Stroke, Palpitations, D. Lung Disease (Asthma, Emphysema, Chronic Cough, Bronchitis, Pneumonia, Tuberculosis, G. Other allergies or reactions? Please, list . Y N E. Seizures, Convulsions, Epilepsy, Fainting or F. Bleeding Disorder, Anemia, Bleeding Tendency, Blood Transfusion? Do you bruise easily? . Y N 11. Is there any past history of Alcohol or Chemical G. Liver Disease (Jaundice, Hepatitis)? . Y N Dependency or Emotional Disorder that may affect 12. Have you had any serious problems associated with 13. Have you or an immediate family member had any problem associated with intravenous anesthesia? . Y N 14. Do you have any other disease, condition or problem not listed above that you think the doctor O. Implants placed anywhere in your body (Heart Valve, Pacemaker, Hip, Knee)? . Y N 15. Do you wish to talk to the doctor privately O. Radiation (X-ray) treatment for Cancer? . Y N P. Clicking or popping of jaw joint, pain near ear, 16. FOR WOMEN ONLY
difficulty opening mouth, grind or clench teeth? . Y N A. Are you Pregnant, or is there any chance
R. Any disease, drug or transplant operation that has depressed your immune system? . Y N C. If you are using Oral Contraceptives, it is important
8. ARE YOU USING ANY OF THE FOLLOWING:
that you understand that antibiotics (and some other medications) may interfere with the effectiveness of oral B. Anticoagulants (Blood Thinners)? . Y N contraceptives. Therefore, you will need to use C. Aspirin or drugs such as Motrin, Aleve, Ibuprofen? Y N mechanical forms of birth control for one complete cycle D. High Blood Pressure medications?. Y N of birth control pills, after the course of antibiotics or other medication is completed. Please consult with your I understand the importance of a truthful Health History to assist the doctor in providing the best care possible. I have had the
opportunity to discuss my Heath History with my doctor.
Signature of Person Completing Health History
Medical Update: I have ready my Health History dated
and confirm that it adequately states past and present

Source: http://www.stonestownsurgerycenter.com/uploads/Health%20History%20Form.pdf