Advanced Family Dentistry Health History Form (Fishers)

Health History Form
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
YesNo
If yes, please provide name and number
YesNo
YesNo
If, yes please list current medications here.
Do you take, or have you taken, Phen-Fen or Redux?*
Have you ever taken Formax, Boniva, Actonel or any other medications containing bisphosphonates?*
YesNo
YesNo
Pregnant/trying to get pregnant?NursingTaking oral contraceptives?None of the above
AspirinPenicillinCodeineAcrylicMetalLatexSulfa DrugsLocal Anesthetics
YesNo
If yes, please list them here
AIDS/HIV positiveAlzheimer's DiseaseAnaphylaxisAnemiaAnginaArthritis/GoutArtificial Heart ValveArtificial JointAsthmaBlood DiseaseBlood TransfusionBreathing ProblemsBruise EasilyCancerChemotherapyChest PainsCold Sores/Fever BlistersCongenital Heart DisorderConvulsionsCortisone MedicineDiabetesDrug AddictionEasily WindedEmphysemaEpilepsy or SeizuresExcessive BleedingExcessive ThirstFainting Spells/DizzinessFrequent CoughFrequent DiarrheaFrequent HeadachesGenital HerpesGlaucomaHay FeverHeart Attack/FailureHeart MurmurHeart PacemakerHeart Trouble/DiseaseHemophiliaHepatitis AHepatitis B or CHerpesHigh Blood PressureHigh CholesterolHives or RashHypoglycemiaIrregular HeartbeatKidney ProblemsLeukemiaLiver DiseaseLow Blood PressureLung DiseaseMitral Valve ProlapseOsteroporsisPain in Jaw JointsParathyroid DiseasePsychiatric CareRadiation TreatmentsRecent Weight LossRenal DialysisRheumatism FeverRheumatismScarlet FeverShinglesSickle Cell DiseaseSinus TroubleSpina BifidaStomach/Intestinal DiseaseStrokeSwelling of LimbsThyroid DiseaseTonsilitisTuberculosisTumors or GrowthsUlcersVenereal DiseaseYellow Jaundice
YesNo
If yes, what was the illness?
Comments:
To the best of my knowledge, the questions on this form have been accurately answered. I undertand that providing incorrect information can be dangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in medical status.
Today's Date*

MonthDayYear
Date
Signature*
Advanced Family Dentistry Cancellation Policy:

If you are unable to keep your scheduled appointment with Dr. Taler, please be courteous and provide a 48-hour notice to any change in the schedule. This is regarding cancellations or rescheduling. Failed appointments will have a charge of $50.00

Thank you for understanding!
Dr. Taler and Advanced Family Dentistry
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