HEALTH  HISTORY

When did you last consult a physician?
Physician's Name
Physician's Address
                                                  Street                                                                                  City                                          State           Zip
                 
1. Are you being treated by a physician for any condition now?   Yes   No
    If so, name the condition(s)
2. Date of last complete physical examination EKG Date
3. Present state of general health   Excellent   Good   Fair   Poor
4. List all major injuries, illnesses, operations, and hospitalization:                                     

YEAR

DISEASE AND/OR PARTS OF BODY

COMPLICATIONS
     
     
     
     
     
        
5. List all medications, including over-the-counter medications (shots, pills, etc.) you are taking now or on occasion.  Please include name, dosage, and how many times per day.    
   
   
   
   
   
   
Have you taken Phen-Fen?   Yes   No Have you ever taken Redux?   Yes   No
       
6. Are you sensitive/allergic to (or ever had a reaction to) Penicillin, local anesthetics, or other drugs?   Yes   No
     If so, name of the drugs:

Office Use
  HT.
  WT.
  B.P.
  PULSE
     
 
 
7. Do you have any of the following?
(Directions: If the answer is YES, put a circle around the YES,  If the answer is NO, put a circle around the NO.   Please answer all of the questions.)
Diabetes (sugar disease)

YES

NO

 Tuberculosis

YES

 NO
Thyroid Trouble YES NO Emphysema YES NO
Heart Trouble YES NO Ulcers YES NO
Rheumatic Fever YES NO Liver Disease YES NO
Heart Murmur YES NO Hepatitis A, B, or C YES NO
Angina Pectoris YES NO Bladder Infection YES NO
Heart Arrhythmia's YES NO Kidney Disease YES NO
High Blood Pressure YES NO Pregnant YES NO
Bleeding Problems YES NO Menopause YES NO
Anemia YES NO Positive HIV Test YES NO
Convulsions YES NO AIDS YES NO
Psychotherapy YES NO Cancer YES NO
Joint or Muscle Aches YES NO Swollen Glands YES NO
Sexually Transmitted Diseases YES NO Night Sweats YES NO
Recent Excessive Weight Loss YES NO Dry Mouth YES NO
Recent Excessive Weight Gain YES NO "Burning Mouth" YES NO


ORAL HISTORY
               

1. Chief complaint at the moment
2. Have you ever had any previous periodontal (gum) treatment? YES NO
3. Do you suffer from pain and/or swelling of your gums? YES NO
4. Do your gums bleed when you brush or floss? YES NO
5. Do you often find yourself clenching and/or grinding your teeth? YES NO
6. Have you ever had an occlusal adjustment or your teeth ground to improve your bite? YES NO
7. Have you ever had a bad reaction to dental anesthetic? YES NO
8. Have you ever had complications following dental surgery? YES NO
9. Do you have any anxieties about dental procedures? YES NO
10. Do you smoke?     If so, how much? YES NO
11. Have you had orthodontics (braces)? YES NO
12. How often do you have your teeth cleaned by a dentist or Hygienist? Last time:
13. Have you had any deep cleanings (root planings)? YES NO
14. How often do you brush your teeth?
15. Has you past dental treatment been:   excellent   good   fair   poor   non-existent
      Please explain:
16. Have you had difficult dental experiences?   as a child   as an adult YES NO
17. Would you be upset if you lost your teeth? YES NO
18. Has there been a lapse in your dental treatment? YES NO
      If Yes, please explain:
19. Are you satisfied with your smile? YES NO
20. Would you like to learn more about dental implants? YES NO
21. What is your... Height Weight

To the best of my knowledge the information provided is current and correct.   I realize it is important to inform the doctor and his/her staff of any changes.   I acknowledge clinical photography may be taken for case documentation and/or educational purposes.

 

Patients Signature ________________________________________    Date ___________________


Witness Signature ________________________________________    Date ___________________