Health_history

HEALTH HISTORY
All Responses Are Kept Confidential ANSWER ALL QUESTIONS BY CIRCLING YES (Y) OR NO (N)
I. Are you presently taking, or have you ever taken any 1. Are you in good health? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Y N of the following Bisphosphonate Medicines: Etidronate (Didronel) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Y N general health in the past year? . . . . . . . . . . . . . . . . . . . . . . . . . . . Y N Tiludronate (Skelid) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Y N Alendronate (Fosamax) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Y N 3. Date of last physical exam ____________________________________ Risedronate (Actonel) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Y N 4. Are you now under a physician's care for Ibandronate (Boniva) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Y N a particular problem? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Y N Pmidronate (Aredia) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Y N Zoledronate (Zometa) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Y N 5. Have you ever had any serious illnesses, Zoledronic Acid (Reclast) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Y N operations or hospitalizations? If so, describe: . . . . . . . . . . . . . . Y N ______________________________________________________________ J. Please list any and all medications taken, including prescription medications, over-the-counter mediations, herbal or holistic ______________________________________________________________ remedies, vitamins or minerals (Use back of form if necessary): 6. Height ____________ Weight ____________ ______________________________________________________________ 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
B. Congenital Heart Disease? . . . . . . . . . . . . . . . . . . . . . . . . . . . . Y N HAD AN ADVERSE REACTION TO:
C. Cardiovascular Disease (Heart Attack, Heart Trouble, A. Local Anesthesia (Novocain, etc.)? . . . . . . . . . . . . . . . . . . . . . Y N Heart Murmur, Coronary Artery Disease, Angina, B. Penicillin or other antibiotics? . . . . . . . . . . . . . . . . . . . . . . . . . Y N High Blood Pressure, Stroke, Palpitations Heart C. Sedatives, Barbiturates? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Y N Surgery, Pacemaker?) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Y N D. Aspirin or lbuprofen? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Y N D. Lung Disease (Asthma, Emphysema, Chronic Cough, E. Codeine or other pain killers? . . . . . . . . . . . . . . . . . . . . . . . . . Y N Bronchitis, Pneumonia, Tuberculosis, Shortness of F. Latex or Rubber Products? . . . . . . . . . . . . . . . . . . . . . . . . . . . . Y N Breath, Chest Pain, Severe Coughing)? . . . . . . . . . . . . . . . . . Y N G. Other allergies or reactions? Please, list . . . . . . . . . . . . . . . . . Y N E. Seizures, Convulsions, Epilepsy, Fainting ______________________________________________________________ or Dizziness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Y N ______________________________________________________________ F. Bleeding Disorder, Anemia, Bleeding Tendency, 10. Do you smoke or chew Tobacco? . . . . . . . . . . . . . . . . . . . . . . . . Y N Blood Transfusion? Do you bruise easily? . . . . . . . . . . . . . . . Y N How much per day? ___________________________________ G. Liver Disease (Jaundice, Hepatitis)? . . . . . . . . . . . . . . . . . . . . Y N 11. Is there any past history of Alcohol or Chemical H. Kidney Disease? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Y N Dependency or Emotional Disorder that may I. Diabetes? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Y N affect the care we provide you? . . . . . . . . . . . . . . . . . . . . . . . . . Y N J. Thyroid Disease (Goiter)? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Y N 12. Have you had any serious problems associated K. Arthritis? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Y N with any previous dental treatment? . . . . . . . . . . . . . . . . . . . . . Y N L. Stomach Ulcers or Colitis? . . . . . . . . . . . . . . . . . . . . . . . . . . . . Y N 13. Have you or an immediate family member had any O. Radiation (X-ray) treatment for Cancer? . . . . . . . . . . . . . . . . Y N problem associated with intravenous anesthesia? . . . . . . . . . . Y N P. Clicking or popping of jaw joint, pain near ear, 14. Do you have any other disease, condition or difficulty opening mouth, grind or clench teeth? . . . . . . . . . Y N problem not listed above that you think the doctor Q. Sinus or Nasal problems? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Y N should know about? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Y N R. Any disease, drug or transplant operation 15. Do you wish to talk to the doctor privately that has depressed your immune system? . . . . . . . . . . . . . . . Y N about anything? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Y N 8. ARE YOU USING ANY OF THE FOLLOWING:
16. FOR WOMEN ONLY
A. Antibiotics? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Y N A. Are you Pregnant, or Is there any chance B. Anticoagulants (Blood Thinners)? . . . . . . . . . . . . . . . . . . . . . . Y N you might be Pregnant? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Y N C. Aspirin or drugs such as Motrin, Aleve, lbuprofen? . . . . . . Y N B. Are you nursing? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Y N D. High Blood Pressure medications. . . . . . . . . . . . . . . . . . . . . . Y N C. If you are using Oral Contraceptives, it is important that E. Steroids (Cortisone, etc.)? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Y N you understand that antibiotics (and some other medications) F. Tranquilizers? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Y N may interfere with the effectiveness of oral contraceptives. G. Insulin or Oral Anti-Diabetic drugs? . . . . . . . . . . . . . . . . . . . Y N Therefore, you will need to use mechanical forms of birth H. Digitalis, Inderal, Nitroglycerin or other heart drug? . . . . . Y N control for one complete cycle of birth control pills, after the course of antibiotics or other medication is completed. Please consult with your physician for further guidance.
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 Health History with my doctor.
SIGNATURE OF PERSON COMPLETING HEALTH HISTORY Medical Update: I have read my Health History dated and confirm that it adequately states past and present conditions.

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