Health History


Your current Physical Health is:

List all current prescription or over the counter medications you are currently taking:


Check yes or no if you currently have or have previously had any of the following diseases, illnesses, or medical complications. Please indicate the date of the event, circle if multiple listed:

Artificial Limbs/Joints/Valves

Arthritis

Blood Transfusion

Diabetes

Drug or Alcohol Abuse

Epilepsy

Heart Attack/Stroke

Hemophilia/Abnormal Bleeding

HIV+/AIDS

Mitral Valve Prolapse

Mental Health Issue/Anxiety/Depression

Severe/Frequent Headaches

Ulcers/Colitis

Cancer/Chemotherapy

Hospitalization for any reason

Unhealed/Current Injuries

High Blood Pressure

Chest Pain/Angina

Dialysis

Cardiac Pacemaker

Heart Surgery

Pneumonia/Bronchitis/Chronic Cough

Contagious Diseases

Snoring

Sleep Apnea/CPAP

Tumor/Growth

Do you use alcohol

Do you use tobacco products

Bruise Easily

Gallbladder Trouble

Anemia

Asthma

Inhaler

Congenital Heart Defect

Difficulty Breathing/Other lung issue

Emphysema

Oxygen use at home

Fever Blisters/Herpes

Heart Murmur

Hepatitis/Jaundice/Liver Disease

Kidney Disease

Tuberculosis

Rheumatic/Scarlet Fever

Shingles

Sinus Problems

Radiation Treatment

General Anesthesia issues

Growth/Sore spots in Mouth

Low Blood Pressure

High Cholesterol

Irregular Heartbeat

Osteoporosis/Osteopenia

Osteonucrosis

Stomach Ulcers/Acid Reflux

Sexually Transmitted Diseases

Problems with Immune System

Delay in Healing

Do you use recreational drugs / Marijuana

Contact Lenses

Eye Disease/Glaucoma


Women Only

Possibility of Pregnancy

Are you Nursing

Are you taking birth control


Are you taking Any of the following?

Blood Thinner

Natural/Herbal/Homeopathic Product

Tranquilizers/Narcotics

Diet Pills

Bone Density Medications

Sleeping Pills/Anti-Depressants


Are you allergic to any of the following?

Local Anesthetic(Numbing meds)

Penicillin

Codeine

Tetracycline

Erythromycin

Valium/Other Tranquilzers

Eggs

Aspirin

Other Antibiotics

Sulfa Drugs

Any Metal / Plastic

Latex

Soy

Sulfites

Other


Dental History

Your current dental health is:

Do you require any antibiotics for dental treatments?

Do you like your smile?

Do your gums bleed?

Have you ever had an injury to your:

Do you have any missing or extra permanent teeth?

Have you ever had a serious/difficult problem with any previous dental work?

Have you ever experienced pain/discomfort in your jaw joint (TMJ/TMD)?

Have you been evaluated for orthodontic treatment?

Have you been let go from a dental practice as a patient?


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