Health information and history

Name______________________________________________ Doctor’s Name_______________________City______________State_______ Date of Last Physical Exam____________________________________ Blood Test or Blood Work-Up________________________________ Are You Presently Taking Any Medications, Drugs, YES NO YES NO Pills, Over-the-Counter Medications, or Having Do You Have High or Low Blood Pressure? ___ ___ Medical Treatments? If Yes, Please list ___ ___ Have You Ever Had a Stroke or CVA? ___ ___ ________________________________________ _____ Have Your Ever Had Any Excessive Bleeding Are You Allergic to or Every Had Any Reaction to Any of the Following: From Any Cut or Incident? ___ ___ Penicillin ____ Codeine____ Latex____ Have You Ever Had Any Seizures or Fainting Spells? ___ ___ Erythromycin____ Aspirin_____ Fluoride____ Have You Ever Been Diagnosed as Having Lupus? ___ ___ Tetracycline ____ Ibuprofen (Advil, Motrin, Nuprin)____ Do You Have Arthritis? ___ ___ Are You Allergic to or Every Had Any Reaction to Any Other Do You Have Any Artificial Joints or Prosthesis? ___ ___ Medications, Drugs, Pills or Treatments? ___ ___ Have You Ever Had Any Lung Disorders or Tuberculosis? ___ ___ If Yes, Please List__________________________________ Have You Ever Had Any Liver Problems or Hepatitis? ___ ___ _________________________________________________ Do You Smoke or Chew Tobacco? ___ ___ Do You Have Asthma, Hay fever, or Allergies in General ___ ___ Have You Ever Had Any Form of Cancer? ___ ___ Have You Ever Been Instructed to Take Any Special Precautions Have You Ever Had Any Kidney Problems? ___ ___ Or Pre-medications before any Dental Appointments? ___ ___ Have You Ever Had an Organ Transplant? ___ ___ If Yes, Please Explain What Medications and Why Do You Have Diabetes or Blood Sugar Problems? ___ ___ _________________________________________________________ Do You Have Glaucoma or Other Eye Problems? ___ ___ __________________________________________________________ Have You Ever Had a Thyroid Problem or Disease? ___ ___ Do You Have Any Heart Ailments or Problems? ___ ___ Have You Ever Had a Substance Abuse Problem? ___ ___ Have You Ever Had Any Type of Heart Surgery Have You Ever Been Treated for Psychiatric Problems? ___ ___ Or Other Cardiac Procedure? ___ ___ Have You Ever Tested Positive for HIV or AIDS? ___ ___ Do You Have Any Congenital Heart Lesions? ___ ___ Do You Presently Have Any Active Venereal Diseases? ___ ___ Have You Ever Had Rheumatic Fever or Please Explain Any Condition, Disease, Situation or Problem Rheumatic Heart Disease? ___ ___ That You Think Our Office Should Know About Have You Ever Been Diagnosed as Having a Heart Murmur? ___ ___ _____________________________________________________ Have You Ever Been Told That You Have a _____________________________________________________ Heart Valve Problem or Prolapsed Heart Valve? ___ ___ ______________________________________________________ Have You Ever Had Recurring Chest Pains or Angina? ___ ___ For Women Only: Do You Have A Cardiac Pacemaker? ___ ___ Are You Presently Using a Birth Control Medication? ___ ___ Do You Have Arteriosclerosis or Other Vascular Problems? ___ ___ Are You Pregnant? ___ ___ Do You Have Any Blood Problems or Anemia? If Yes, What is your Due Date? __________________ APPOINTMENTS-A minimum charge will be made for failed or cancelled appointments without prior notification of at least 24 hours. This fee covers only a portion of the overhead such as salaries, electric, heat, etc., which still has to be paid whether you are present or not. Once an appointment is made, please remember this time has been reserved just for you. Any change in your appointments affects many patients; please be considerate. CONSENT- To the best of my knowledge, all of the preceding answers are correct. If I every have any change in my health, or if my medications change, I will inform this office at the next appointment without fail. I hereby consent to allow diagnosis, proper dental care and treatment to be performed by this practice for myself or the above named individual until further notice. I understand there are no guarantees or warranties in health or dental care. SIGNATURE__________________________________________________________________________________________Date: __________________________ (Parent or Guardian, if Patient is a Minor)

Source: http://www.goudarzidental.net/documents/pdf/HEALTH%20INFORMATION%20AND%20HISTORY.pdf