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Health History Form

Include area code
Include area code
Sex:
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Include area code
If you are completing this form for another person, what is your relationship to that person?
Do you have any of the following diseases or problems:

(Select DK if you Don’t Know the answer to the question)

Yes No DK
Active Tuberculosis
Persistent cough greater than a 3 week duration
Cough that produces blood
Been exposed to anyone with tuberculosis

Dental Information

For the following questions, please select Yes, No or DK.
Yes No DK
Do your gums bleed when you brush or floss?
Are your teeth sensitive to cold, hot, sweets or pressure?
Is your mouth dry?
Have you had any periodontal (gum) treatments?
Have you ever had orthodontic (braces) treatment?
Have you had any problems associated with previous dental treatment?
Is your home water supply fluoridated?
Do you drink bottled or filtered water?
If yes, how often?
Are you currently experiencing dental pain or discomfort?
Yes No DK
Do you have earaches or neck pains?
Do you have any clicking, popping or discomfort in the jaw?
Do you brux or grind your teeth?
Do you have sores or ulcers in your mouth?
Do you wear dentures or partials?
Do you participate in active recreational activities?
Have you ever had a serious injury to your head or mouth?

Medical Information

Please select your response to indicate if you have or have not had any of the following diseases or problems.
Yes No DK
Are you now under the care of a physician?
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Are you in good health?
Has there been any change in your general health within the past year?
Yes No DK
Have you had a serious illness, operation or been hospitalized in the past 5 years?
Are you taking or have you recently taken any prescription or over the counter medicine(s)?

Medical Information

Please select your response to indicate if you have or have not had any of the following diseases or problems.
Yes No DK
Do you wear contact lenses?
Joint Replacement. Have you had an orthopedic total joint (hip, knee, elbow, finger) replacement?
Are you taking or scheduled to begin taking an antiresorptive agent (like Fosamax®, Actonel®, Atelvia, Boniva®, Reclast, Prolia) for osteoporosis or Paget’s disease?
Since 2001, were you treated or are you presently scheduled to begin treatment with an antiresorptive agent (like Aredia®, Zometa®, XGEVA) for bone pain, hypercalcemia or skeletal complications resulting from Paget’s disease, multiple myeloma or metastatic cancer?
Yes No DK
Do you use controlled substances (drugs)?
Do you use tobacco (smoking, snuff, chew, bidis)?
If so, how interested are you in stopping?
Do you drink alcoholic beverages?
WOMEN ONLY Are you:
Pregnant?
Taking birth control pills or hormonal replacement?
Nursing?
Allergies. Are you allergic to or have you had a reaction to:

To all yes responses, specify type of reaction.

Yes No DK
Local anesthetics
Aspirin
Penicillin or other antibiotics
Barbiturates, sedatives, or sleeping pills
Sulfa drugs
Codeine or other narcotics
Yes No DK
Metals
Latex (rubber)
Iodine
Hay fever/seasonal
Animals
Food
Other
Yes No DK
Artificial (prosthetic) heart valve
Previous infective endocarditis
Damaged valves in transplanted heart
Congenital heart disease (CHD)
Unrepaired, cyanotic CHD
Repaired (completely) in last 6 months
Repaired CHD with residual defects

Except for the conditions listed above, antibiotic prophylaxis is no longer recommended for any other form of CHD.

Yes No DK
Cardiovascular disease
Angina
Arteriosclerosis
Congestive heart failure
Damaged heart valves
Heart attack
Heart murmur
Low blood pressure
High blood pressure
Other congenital heart defects
Yes No DK
Mitral valve prolapse
Pacemaker
Rheumatic fever
Rheumatic heart disease
Abnormal bleeding
Anemia
Blood transfusion
Hemophilia
AIDS or HIV infection
Arthritis
Yes No DK
Autoimmune disease
Rheumatoid arthritis
Systemic lupus erythematosus
Asthma
Bronchitis
Emphysema
Sinus trouble
Tuberculosis
Cancer/Chemotherapy/Radiation Treatment
Chest pain upon exertion
Chronic pain
Diabetes Type I or II
Eating disorder
Malnutrition
Gastrointestinal disease
G.E. Reflux/persistent heartburn
Ulcers
Thyroid problems
Stroke
Yes No DK
Glaucoma
Hepatitis, jaundice or liver disease
Epilepsy
Fainting spells or seizures
Neurological disorders
Sleep disorder
Do you snore?
Mental health disorders
Recurrent Infections
Kidney problems
Night sweats
Osteoporosis
Persistent swollen glands in neck
Severe headaches/migraines
Severe or rapid weight loss
Sexually transmitted disease
Excessive urination
Has a physician or previous dentist recommended that you take antibiotics prior to your dental treatment?
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Do you have any disease, condition, or problem not listed above that you think I should know about?

NOTE: Both doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment.
I certify that I have read and understand the above and that the information given on this form is accurate. I understand the importance of a truthful health history and that my dentist and his/her staff will rely on this information for treating me. I acknowledge that my questions, if any, about inquiries set forth above have been answered to my satisfaction. I will not hold my dentist, or any other member of his/her staff, responsible for any action they take or do not take because of errors or omissions that I may have made in the completion of this form.

For Completion By Dentist
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