torrimed-Health

HEALTH HISTORY
Patient's Name:*
Date of Birth:*

MonthDayYear
Height:*
Weight:*
Date:*

MonthDayYear
Answer all questions by select Yes (Y) or No (N). All responses are kept confidential
Are you in good health?*

yesNo
Has there been any change in your general health in the past year?*

yesNo
Date of last physical exam:*

MonthDayYear
Are you now under a physician's care for a particular problem?*

yesNo
Have you ever had any serious illnesses, operations or hospitalizations?*

yesNo
If so, describe:
DO YOU HAVE OR HAVE YOU EVER HAD
Rheumatic Fever or Rheumatic Heart Disease?*

yesNo
Congenital Heart Disease?*

yesNo
Cardiovascular Disease (Heart Attack, Heart Trouble, Heart Murmur, Coronary Artery Disease, Angina, High Blood Pressure, Stroke, Palpitations, Heart Surgery, Pacemaker)?*

yesNo
Lung Disease (Asthma, Emphysema, COPD, Chronic Cough, Bronchitis, Pneumonia, Tuberculosis, Shortness of Breath, Chest Pain, Severe Coughing)?*

yesNo
Seizures, Convulsions, Epilepsy, Fainting or Dizziness?*

yesNo
Bleeding Disorder, Anemia, Bleeding Tendency, Blood Transfusion?*

yesNo
Do you bruise easily?*

yesNo
Liver Disease (Jaundice, Hepatitis)?*

yesNo
Kidney Disease?*

yesNo
Diabetes?*

yesNo
Thyroid Disease (Goiter)?*

yesNo
Arthritis?*

yesNo
Stomach Ulcers or Colitis?*

yesNo
Glaucoma?*

yesNo
Osteoporosis?*

yesNo
Implants placed any where in your body (Heart Valve, Pacemaker, Hip, Knee)?*

yesNo
Radiation (X-ray) treatment for Cancer?*

yesNo
Clicking or popping of jaw joint, pain near ear, difficulty opening mouth, grind or clench teeth?*

yesNo
Sinus or Nasal problems?*

yesNo
Any disease, drug ortransplant operation that has depressed your immune system?*

yesNo
ARE YOU USING ANY OF THE FOLLOWING:
Antibiotics?*

yesNo
Anticoagulants (Blood Thinners)?*

yesNo
Aspirin or drugs such as Motrin, AlleveIbuprofen?*

yesNo
High Blood Pressure medications?*

yesNo
Steroids (Cortisone.Prednisone, etc.)?*

yesNo
Tranquilizers?*

yesNo
Insulin or Oral Anti-Diabetic drugs?*

yesNo
Digitalis, lnderal,Nitroglycerin or other heart drug?*

yesNo
Are you taking or have you ever taken Bisphosphonates for osteoporosis, multiple myeloma or other cancers (Reclast, Fosamax, Actonel, Boniva, Aredia, Zometa)?*

yesNo
Have you ever been advised not to take a medication?*

yesNo
Please list any and all medications taken, including prescription medications, diet drugs, over-the-counter medications, herbal or holistic remedies, vitamins or minerals:*
ARE YOU ALLERGIC TOOR HAVE YOU HAD AN ADVERSE REACTION TO:
Local Anesthesia (Novocaine, etc.)?*

yesNo
Penicillin or other antibiotics?*

yesNo
Sedatives, Barbiturates?*

yesNo
Aspirin or Ibuprofen?*

yesNo
Codeine or other pain killers?*

yesNo
Latex or Rubber products?*

yesNo
Metal of any kind?*

yesNo
Chemicals or jewelry (rash or sensitivity)?*

yesNo
Food products?*

yesNo
Other allergies or reactions?*

yesNo
Please List:
Do you smoke or chew Tobacco?*

yesNo
How much per day?
Is there any past history of Alcohol or Chemical Dependency or Emotional Disorder that may affectthe care we provide you?*

yesNo
Have you had any serious problems associated with any previous dental treatment?*

yesNo
Have you or animmediate family member had any problem associated with intravenous anesthesia?*

yesNo
Do you have any other disease, condition or problem not listed above that you think the doctor should know about?*

yesNo
Do you wish to talk to the doctor privately about any thing?*

yesNo
Have you ever had a bone density scan?*

yesNo
FOR WOMEN ONLY:
Are you Pregnant, or is there any chance you might be Pregnant?

yesNo
Are you nursing?

yesNo
If you are using Oral Contraceptives, it is important that you understand that antibiotics (and some other medications) may interfere with the effectiveness of oral contraceptives. Therefore, you will need to use mechanical forms of birth control for one complete cycle of birth control pills, after the course of medication is completed.
Reason for your Visit*
I understand the importance of a truthful and complete Health History to assist my dentist in providing the best care possible. I have had the opportunity to discuss my Health History with my dentist.
Date:*

MonthDayYear
Signature of Person Completing Health History:*

Clear
Doctor's initials
Should be Empty:

HEALTH HISTORY

DO YOU HAVE OR HAVE YOU EVER HAD

ARE YOU USING ANY OF THE FOLLOWING:

ARE YOU ALLERGIC TOOR HAVE YOU HAD AN ADVERSE REACTION TO:

FOR WOMEN ONLY:

Doctor's initials