Patient Health History
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1PATIENT HEALTH HISTORY
Patient: __________________ Date: _________
Who is your dentist? ___________________
When was your last: dental visit? ________________ cleaning? ________________
Do you have any periodontal (gum) problems (i.e. gum disease, deep pockets, etc.)? Yes
No
If so, please explain: ______________________________
Have you ever had or currently have any of the following? (Circle YES or NO)
Heart Murmur
Yes
No
High blood pressure
Yes
No
Rheumatic Fever
Yes
No
Low blood pressure
Yes
No
Prosthetic joint replacement
Yes
No
Diabetes
Yes
No
Heart valve replacement
Yes
No
Anemia
Yes
No
Heart stent
Yes
No
Glaucoma
Yes
No
Tuberculosis
Yes
No
Osteoporosis
Yes
No
Cancer
Yes
No
Osteopenia
Yes
No
Kidney disease
Yes
No
Multiple myeloma
Yes
No
HIV infection
Yes
No
Bone metastases of cancer
Yes
No
Endocrine problems
Yes
No
Hypercalcemia
Yes
No
Nervous disorders
Yes
No
Paget’s disease
Yes
No
Liver disease
Yes
No
Radiation therapy
Yes
No
Prolonged bleeding
Yes
No
Bone disorders
Yes
No
Seizure disorders
Yes
No
Asthma
Yes
No
Hepatitis
Yes
No
AIDS
Yes
No
Fainting
Yes
No
Heart problems
Yes
No
Other __________________
Yes
No
Do you need to take antibiotics before your dental appointments? Yes
No
If so, why? _____________
Have you been under the care of a physician in the past 2 years?
Yes
No
If so, why? _____________
Are you taking or have you EVER taken bisphosphonates (including but not limited to Fosamax®, Fosamax
plus D®, Didronel®, Boniva®, Aredia®, Skelid®, Zometa®, etc)?
Yes
No
If so, which one(s)? _____________________
List any drugs or medications now being taken (including birth control medications):
Medication ________________ Taken for ________________
Medication ________________ Taken for ________________
Have you ever been hospitalized?
Yes
No
If so, for what? _______________________
Do you have allergies to any of the following (if so, explain in detail next to the item):
Local anesthetics
Yes
No
Aspirin
Yes
No
Ibuprofen
Yes
No
Penicillin or other antibiotics
Yes
No
Sulfa drugs
Yes
No
Codeine or other narcotics
Yes
No
Metals (jewelry, etc)
Yes
No
Vinyl
Yes
No
Latex (gloves, balloons, etc)
Yes
No
Acrylic
Yes
No
Foods (specify)___________
Yes
No
Other (specify)___________
Yes
No
Are you pregnant?
Yes
No
Has there ever been an injury to the face, jaw, or teeth?
Yes
No If so, explain? ___________________
Has there ever been a thumbsucking habit?
Yes
No If so, until what age? ______________
Are there any speech problems?
Yes
No
Are there any TMJ (jaw joint) problems?
Yes
No If yes, explain ___________________
Is there anything else we should know (whether it be medically, socially, or religiously related) about
this patient that hasn’t otherwise been addressed?
Yes
No If so, please explain: ______________
Signature of Patient, Parent, or Legal Guardian: ____________________________
Date: __________
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