Microsoft word - health information and history form_04-30-07.doc

Health Information and History Today’s Date:
Patient’s Name:
Date of Birth:
If you are completing this form for another person: Your name: Emergency Contact: (If not listed above)
Primary Physician:
Other Physicians & Specialists
1. With in the last 3 years, have you been hospitalized or had surgery?
__ Yes __ No
2. Have you ever been instructed to take ANY medications or
take ANY special precautions before any dental appointments*?
__ Yes __ No
3. Are you taking ANY drugs, medications, or treatments at this time?
__ Yes __ No
(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*?
__ Yes __ No
Name of facility performing the treatment : 4. Are you taking or have you ever taken / been treated with a Bisphosphonate (Fosamax)? __ Yes __ No
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?
__ Yes __ No
Continued on next page…
Reviewed By:
Health Information and History (continued)
Patient’s Name:
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 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 Women Only:
Any artificial joint, joint surgery, or prosthesis 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? __ Yes __ No
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 wil be informed of the changes without fail. I also consent to al ow 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 al ow 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. (Parent or guardian, if patient is a minor) Reviewed By:

Source: http://healthysmilesofga.com/wp-content/uploads/2013/03/Health-Information-and-History-Form-2013-revised.pdf