Microsoft word - new health 1.doc

Health Information
Patient Name:

Have you experienced any of the following?

Angina/Chest Pain
Frequent Cough
Pain in Jaw Joints
Breathing Problems
Frequent Diarrhea
Recent Weight Loss
Bruise Easily
Frequent Urination
Sinus Problems
Difficulty Swallowing
Hives or Rash
Swollen Joints
Excessive Thirst
Fainting or Dizziness
Are you allergic to:
Local anesthetic
Nitrous Oxide
Other: ______________

Have you ever had any of the following? Please check those that apply:

Glaucoma/Eye Disease
Radiation Treatment
Allergies (Pollen Dust)
Heart Attack/Failure
Scarlet/Rheumatic Fever
Alzheimer’s Disease
Heart Murmur/Irregularity
Sickle Cell Disease
Hepatitis A / B / C
Skin Disease
Artificial Heart Valve
High Blood Pressure
Stomach Problems/ IBS
Artificial Joints
Intestinal Problems
Kidney Problems
Thyroid Disease
Blood Disease
Liver Disease
Cold Sores
Low Blood Pressure
Tumors or Growths
Congenital Heart Disorder
Lung Disease
Cortisone Medicine
Mitro Valve Prolapse
Drug/Alcohol Addiction
Dry Mouth
Emphysema/Lung Disease
Periodontal Treatment
Epilepsy or Seizures
Psychiatric Care

Do you need to Pre-Medicate for your dental appointment?
Yes No
Have you had any previous dental complications? Yes No If yes, please explain______________________________________
Are you currently under the care of a physician? Yes No If yes, please explain_______________________________________
Have you been admitted to a hospital or needed emergency care during the past two years? Yes No
If yes, please explain_________________________________________________________________________________________
Women: (please check) pregnant / trying to get pregnant Nursing Taking oral contraceptives

Have you taken any supplements, tobacco, and alcohol or had significant weight loss in the last 3 months?______________________
List all current medications:_____________________________________________________________________________________

To the best of my knowledge, all the preceding answers and information provided are true and correct. If I ever have any
change in my health, I will inform the doctor at the next appointment without fail.
________________________________________________________________________________ Date: ___________________
Signature of patient, parent or guardian
Doctor: ________________________________________________________ Date:_____________ Patient BP: ____________


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