Rockdental-Health History

Health History
Patient's Name*

First NameLast Name
How would you rate your general health?

ExcellentGoodFairBad
Are you under the care of a physician?

YesNo
Please explain
Physician’s Name
Phone
Do you have, or have you ever had, any of the following (please mark all that apply):

Heart problemsThyroid problemsBlood DisorderDiabetesHeart murmurLung problemsBlood TransfusionNeurological disorderHeart valve issuesAsthmaAnemiaHigh blood pressureAllergiesHIV/AIDSEpilepsyStrokeHay feverVenereal diseaseDepressionRheumatic FeverLatex SensitivityTumors or GrowthsAnxietyOrgan TransplantKidney or liver DiseaseCancerSmoking/TobaccoArtificial JointHepatitis A B CChemotherapyAlcohol AbuseArthritisUlcers, GastritisRadiation TherapyDrug Abuse
Do you have any disease, condition or problem not listed above?

YesNo
Please explain
Have you been hospitalized and/or had surgery?

YesNo
Please explain
Please list all medications and supplements you are taking :
Are you allergic or sensitive to any of these medications:

PenicillinAspirinCarbocaineValiumTetracyclineTylenolNovocaineCodeineErythomycinAdvil/IbuprofenXylocaineDexamethazone
Any other medications you are allergic or sensitive to?
Have you received the Covid-19 Vaccines?

YesNo
Women: Are you pregnant?

YesNo
Are you nursing?

YesNo
Taking Birth Control Pills?

YesNo
Comments/Remarks
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty: