Health History Form

As required by law, our office adheres to written policies and procedures to protect the privacy of information about you that we create, receive or maintain. Your answers are for our records only and will be kept confidential subject to applicable laws. Please note that you will be asked some questions about your responses to this questionnaire and there may be additional questions concerning your health. This information is vital to allow us to provide appropriate care for you. This office does not use this information to discriminate.

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You may share my medical/dental history with:

Do you have any of the following diseases or problems:

(Check DK if you Don't Know the answer to the question)

Yes   No   DK

Active Tuberculosis
     
Persistent cough greater than a 3 week duration
     
Cough that produces blood
     
Been exposed to anyone with tuberculosis
     

If you answer yes to any of the 4 items above, please stop and return this form to the receptionist.

Dental Information For the following questions, please check your responses to the following questions.

Yes   No   DK

Yes   No   DK

Do your gums bleed when you brush or floss?
     
Do you have earaches or neck pain?
     
Are your teeth sensitive to cold, hot, sweets or pressure?
     
Do you have any clicking, popping or discomfort in the jaw?
     
Does food or floss catch between your teeth?
     
Do you brux or grind your teeth?
     
Is your mouth dry?
     
Do you have sores or ulcers in your mouth?
     
Have you had any periodontal (gum) treatments?
     
Do you wear dentures or partials?
     
Have you ever had orthodontic (braces) treatment?
     
Do you participate in active recreational activities?
     
Have you had any problems associated with previous dental treatment?
     
Have you ever had a serious injury to your head or mouth?
     
Is your home water supply fluoridated?
     
Date of your last dental exam:
Do you drink bottled or filtered water?
     
What was done at that time?
If yes, how often? Check one:
Are you currently experiencing dental pain or discomfort?
     
Date of last dental x-rays:

What is the reason for your dental visit today?

How do you feel about your smile?

Medical Information Please check your response to indicate if you have or have not had any of the following diseases or problems.

Yes   No   DK

Yes   No   DK

Are you now under the care of a physician?
     
Have you had a serious illness, operation or been hospitalized in the past 5 years?
     
Physician Name:
Phone:
If yes, what was the illness or problem?
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Address/City/State/Zip:
Are you taking or have you recently taken any prescription or over the counter medicine(s)?
     
Are you in good health?
     
If so, please list all, including vitamins, natural or herbal preparations and/or diet supplements:
Has there been any change in your general health within the past year?
     
If yes, what condition is being treated?
Date of last physical exam:
© 2007 American Dental Association
Form S500
--------------- PAGE END ----------------
Medical Information Please check your response to indicate if you have or have not had any of the following diseases or problems.
(Check DK if you Don't Know the answer to the question)

Yes   No   DK

Yes   No   DK

Do you wear contact lenses?
     
Do you use controlled substances (drugs)?
     
Joint Replacement. Have you had an orthopedic total joint (hip, knee, elbow, finger) replacement?
     
Do you use tobacco (smoking, snuff, chew, bidis)?
     
Date: If yes, have you had any complications?
If so, how interested are you in stopping?
Are you taking or scheduled to begin taking either of the medications, alendronate (Fosamax®) or risedronate (Actonel®) for osteoporosis or Paget's disease?
     
Do you drink alcoholic beverages?
     
If yes, how much alcohol did you drink in the last 24 hours?
If yes, how much do you typically drink in a week?
Since 2001, were you treated or are you presently scheduled to begin treatment with the intravenous bisphosphonates (Aredia® or Zometa®) for bone pain, hypercalcemia or skeletal complications resulting from Paget's disease, multiple myeloma or metastatic cancer?
     
Date Treatment began:
WOMEN ONLY Are you:
Pregnant?
     
Number of weeks:
Taking birth control pills or hormonal replacement?
     
Nursing?
     
Allergies - Are you allergic to or have you had a reaction to:
To all yes responses, specify type of reaction.

Yes   No   DK

Local anesthetics
     
Aspirin
     
Penicillin or other antibiotics
     
Barbiturates, sedatives, or sleeping pills
     
Sulfa drugs
     
Codeine or other narcotics
     

Yes   No   DK

Metals
     
Latex (rubber)
     
Iodine
     
Hay fever/seasonal
     
Animals
     
Food
     
Other
     
Please check your response to indicate if you have or have not had any of the following disease or problems.

Yes   No   DK

Yes   No   DK

Yes   No   DK

Artificial (prosthetic) heart valve
     
Previous infective endocarditis
     
Damaged valves in transplanted heart
     
Congenital heart disease (CHD)
Unrepaired, cyanotic CHD
     
Repaired (completely) in last 6 months
     
Repaired CHD with residual defects
     
Except for the conditions listed above, antibiotic prophylaxis is no longer recommended for any other form of CHD.

Yes   No   DK

Cardiovascular disease
     
Angina
     
Arteriosclerosis
     
Congestive heart failure
     
Damaged heart valves
     
Heart attack
     
Heart murmur
     
Low blood pressure
     
High blood pressure
     
Other congenital heart defects
     

Yes   No   DK

Mitral valve prolapse
     
Pacemaker
     
Rheumatic fever
     
Rheumatic heart disease
     
Abnormal bleeding
     
Anemia
     
Blood transfusion
     
If yes, date:
Hemophilia
     
AIDS or HIV infection
     
Arthritis
     
Autoimmune disease
     
Rheumatoid arthritis
     
Systemic lupus erythematosus
     
Asthma
     
Bronchitis
     
Emphysema
     
Sinus trouble
     
Tuberculosis
     
Cancer/Chemotherapy/Radiation Treatment
     
Chest pain upon exertion
     
Chronic pain
     
Diabetes Type I or II
     
Eating disorder
     
Malnutrition
     
Gastrointestinal disease
     
G.E. Reflux/persistent heartburn
     
Ulcers
     
Thyroid problems
     
Stroke
     
Glaucoma
     
Hepatitis, jaundice or liver disease
     
Epilepsy
     
Fainting spells or seizures
     
Neurological disorders
     
If yes, specify:
Sleep disorder
     
Mental health disorders
     
Specify:
Recurrent Infections
     
Type of infection:
Kidney problems
     
Night sweats
     
Osteoporosis
     
Persistent swollen glands in neck
     
Severe headaches/migraines
     
Severe or rapid weight loss
     
Sexually transmitted disease
     
Excessive urination
     
Has a physician or previous dentist recommended that you take antibiotics prior to your dental treatment?
     
Name of physician or dentist making recommendation:
Phone:
Do you have any disease, condition, or problem not listed above that you think I should know about?
     
Please explain:

NOTE: Both Doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment.
I certify that I have read and understand the above and that the information given on this form is accurate. I understand the importance of a truthful health history and that my dentist and his/her staff will rely on this information for treating me. I acknowledge that my questions, if any, about inquiries set forth above have been answered to my satisfaction. I will not hold my dentist, or any other member of his/her staff, responsible for any action they take or do not take because of errors or omissions that I may have made in the completion of this form.

Type Name for Electronic Signature:
Date: