Microsoft word - health information and history form_04-30-07.doc
Health Information and History
: ______________________________________________________ Date of Birth
If you are completing this form for another person: Your name: ________________________________________ Phone: ________________ Relationship: ________________
: (If not listed above)
Name: ____________________________________________ Phone: ________________ Relationship: ________________
: __________________________________ Phone: _________________ City & State: ________________
Date of last physical examination: ______________________ Date of last blood test/work up: ________________________
Other Physicians & Specialists
Name: ___________________________ Specialty: _______________ Phone: ______________ City & State: ____________ Name: ___________________________ Specialty: _______________ Phone: ______________ City & State: ____________
1. With in the last 3 years, have you been hospitalized or had surgery?
If Yes, please give reasons and dates: __________________________________________________
2. Have you ever been instructed to take ANY medications or
take ANY special precautions before any dental appointments*?
If Yes, please explain: _______________________________________________________________
3. Are you taking ANY drugs, medications, or treatments at this time?
(If you brought a complete written list with you, give that to the receptionist instead) Prescribed: ________________________________________________________ ________________________________________________________________ Over-the-counter (OTC) medications (such as Aspirin, Advil, allergy medication, sleeping aids, etc):
Vitamins, natural or herbal preparations and/or dietary supplements:
Are you having or have you ever had radiation or chemotherapy treatments*
If Yes, for how long?______________ Name of facility performing the treatment :_______________
4. Are you taking or have you ever taken / been treated with a Bisphosphonate (Fosamax)?
5. Are you allergic to or have you ever experienced an unusual reaction to:
6. Are you allergic to or have you ever had any reaction to any of the following drugs?
___Penicillin (or related drugs)
___Aspirin / Ibuprofen (Advil, Motrin, Nuprin)
7. Have you had an allergic reaction or unusual response to
ANY other medications, drugs, pills, or treatments?
If Yes, please list :___________________________________________________________
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Copyright LED Dental Inc
Health Information and History (continued)
8. Do you have, or have you ever had, any of the following?
(Please check Yes or No for each question)
Tuberculosis, emphysema or lung disorder
If Yes, type & date _____________________
If Yes, date ___________________________
Rheumatic heart disease / rheumatic fever
Heart valve(s) damage / Mitral valve prolapse
Ulcers, acid reflux, or stomach problems
(Lupus, HIV, AIDS, radiation immune problem, etc.)
An active sexually transmitted disease (STD) ___ ___
Been treated for any psychiatric condition
Excessive bleeding from any cut or incident
Any artificial joint, joint surgery, or prosthesis
If Yes, what is your due date: ____________
If Yes, what join t or area: __________________
When was operation done: _________________
Hepatitis, jaundice, or other liver problems
Are you taking hormone replacement therapy ___ ___
9. Do you have any other conditions, diseases, or medical problems, or is there ANY other
information that you would like us to know about, or that we should be made aware of?
If Yes, please explain: __________________________________________________________________________
CONSENT — To the best of my knowledge, all of the preceding information is correct and if there is ever any change in health, or medications, this practice will be informed of the changes without fail. I also consent to allow this practice to contact any healthcare provider(s) and to have the patient’s health information released to aid in care and treatment. I also hereby consent to allow diagnosis, proper health care and treatment to be performed by this practice for 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)
Copyright LED Dental Inc
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