Health Questionnaire Template (Sample)
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1
2January 07, 201
Health Questionnaire Update
Name
Date of Birth
Age___ Sex: M F Employer: _________________
_________________________
_________
Address: _____________________City ___________State ___Zip______ Phone #:______________
Emergency Contact: ___________________________ Email Address: _______________________ Employer:____________
Do you have or have you had any of the following?
(Please check)
Yes
No
Yes No
Heart
Lungs
*Bacterial Endocarditis (SBE)
*Tuberculosis -- currently or in past
*Congenital Heart Disease / Defect:
Difficulty breathing
*Artificial Heart Valve -- Date:
Allergy to latex, iodine, sulfites, or red dye
*Congestive Heart Failure
Asthma , Emphysema, or other Lung Disease
Pain / Angina
Blood
Stroke
*Coumadin (Warfarin) use
High Blood Pressure
Anemia or Abnormal Bleeding or Bruising
Pacemaker / Defibrillator or other Artificial Device /
Blood transfusion
Implant -- Date:
Heart Disease or Heart Attack -- Dates:
Methemoglobinemia
Kidneys
Other blood disorders: __________________
*Kidney Problems or Dialysis (circle)
Other
End stage renal failure:
*Joint Replacement (hip, knee, ankle)
Date of last dialysis:
Chemotherapy or Radiation -- Dates:
Liver and Endocrine
Cancer/tumors -- Dates:
Please list type:_________________
Diabetes:
Type I
Type II
(circle)
Thyroid Problems ---
High or
Low
Is your diabetes controlled
Physical or Mental Condition that requires special
What is your HbA1c: ____________
consideration:
Hepatitis -- treated in past or currently active
Spleen removed: (date)
(please circle) A B C D E
Other Liver Disease:
Ulcers
Immunosuppressive Conditions:
*Organ Transplant -- Date:
Steroid Use (e.g. prednisone) -- Dates:
Herpes
Lupus (SLE)
Osteoporosis or osteopetrosis
HIV or Aids
Sinus complications
Leukemia:
Epilepsy, Seizures, or Nervous System Disease
Chemical Dependency
*Dental Assistants – this indicates patient will need a DDS consult prior to treatment, please bring to dentist attention immediately!
Do you have any other diseases or conditions not mentioned above (please list)?_______________________________________
_____________________________________________________________________________________________________________
Allergies (please circle):
Penicillin (amoxicillin)
Other Antibiotics (Clindamycin, azithromycin) : ______________
Ibuprofen
Other Pain Medications (hydrocodone, oxycodone):_________________
Aspirin
Sulfa Drugs
Tylenol
Latex
Codeine
Seasonal: __________________________
Local Anesthetic (Novocaine, Lidocaine):_____________________________________________________________
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Parent category: Life