Bridgeview Dental Associates

BRIDGEVIEW DENTAL ASSOCIATES

HEALTH HISTORY

Patient’s Name:______Date:______

Physician’s Name:______

Answer all questions by circling Y (yes) or N (no). All responses are kept confidential.

Is your general health good? / Y / N
Has there been a change in your health within the last year? / Y / N
Have you been hospitalized or had a serious illness in the last 3 years?
If yes, why?______ / Y / N
Are you being treated by a physician now? For what?______
Date of last medical exam?______ Date of last dental exam:______ / Y / N
Have you had problems with prior dental treatment? / Y / N
Are you in pain now? / Y / N

Do you have or have you ever had (circle what applies):

Rheumatic fever or rheumatic heart disease? / Y / N
Congenital heart disease? / Y / N
Cardiovascular disease (heart attack, heart trouble, heart murmur, coronary artery disease, angina, high blood pressure, stroke, palpitations, heart surgery, pacemaker)? / Y / N
Lung disease (asthma, emphysema, chronic cough, bronchitis, pneumonia, tuberculosis, shortness of breath, chest pain, severe coughing)? / Y / N
Seizures, convulsions, epilepsy, fainting or dizziness? / Y / N
Bleeding disorder, anemia, bleeding tendency, blood transfusion, bruise easily? / Y / N
Liver disease (jaundice, hepatitis)? / Y / N
Kidney disease? / Y / N
Diabetes? / Y / N
Thyroid disease (goiter)? / Y / N
Arthritis? / Y / N
Stomach ulcers or colitis? / Y / N
Glaucoma? / Y / N
Implants (heart valve, pacemaker, hip, knee, tooth, other)? / Y / N
Radiation (xray) or chemotherapy, immunotherapy for cancer? / Y / N
Clicking or popping of the jaw joint, pain near ear, difficulty opening mouth, grinding or clenching teeth)? / Y / N
Sinus or nasal problems? / Y / N
Any disease, drug or transplant operation that has depressed your immune system? / Y / N

Are you using any of the following medications (circle what applies)?

Antibiotics? / Y / N
Anti-coagulants (blood thinners, Coumadin)? / Y / N
NSAIDs (Aspirin, Tylenol, Aleve, Motrin, Ibuprofen, Naproxen)? / Y / N
High blood pressure medications? / Y / N
Steroids (Cortisone, Prednisone)? / Y / N
Insulin or oral anti-glycemic medications? / Y / N
Tranquilizers? / Y / N

Are you allergic to or have had an adverse reaction to:

Local anesthesia (Novocaine, etc.)? / Y / N
Penicillin or other antibiotics? / Y / N
Sedatives, barbiturates, narcotics, codeine? / Y / N
Aspirin, Ibuprofen, or other NSAIDs? / Y / N
Latex or rubber products? / Y / N
Sulfa or sulfur? / Y / N
Soy or soy products? / Y / N
Other allergies or reactions? Please list:______
______ / Y / N

Are you taking:

Recreational drugs? Please list:______/ Y / N
Drugs, medications, over-the-counter medicines (including aspirin), natural remedies? Please list:______/ Y / N
Tobacco in any form? Please list:______/ Y / N
Alcohol? Quantity per day:______/ Y / N

Signature of person completing health history:Date:

______

Doctor’s initials:______

Medical update: I have read my health history dated ______and confirm that it adequately states past and present conditions:

Date:______Exceptions or changes:______

______

Patient’s signature:______Doctor’s initials_____