Form 21430-003 -Health History Form - Burlington County Page 2

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yes
No
DK
yes
No
DK
Do you wear contact lenses? ................................................................ o
Since 2001, were you treated or are you presently scheduled to begin
o
o
treatment with the intravenous biophosphonates (Aredia® or Zometa®)
JoiNt rePlaCemeNt:
for bone pain, hypercalcemia or skeletal complications resulting from
Have you had an orthopedic joint replacement (hip, knee,
Paget’s disease, multiple myeloma or metastatic cancer? ....................o
o
o
elbow or finger) replacement? .............................................................o
o
o
/
/
/
/
Date treatment began: ______________________
Date: ____________________________
Do you use controlled substances (drugs)? ...........................................o
o
o
If yes, have you had any complications? ...............................................o
o
o
Do you use tobacco (smoking, snuff, chew, bidis)? ...............................o
o
o
Are you taking or scheduled to begin taking either of the following
medications: alendronate (Fosomax®) or risedronate (Actonel®) for
If yes, are you interested in stopping? Circle one:
YES
SOMEWHAT
NO
osteoporosis or Paget’s disease? ........................................................... o
o
o
WomeN oNly:
Are you pregnant? ................................................................................o
Are you taking birth control pills or hormonal replacement? ...............o
o
o
o
o
If yes, how many weeks? ____________________
Are you nursing? .................................................................................. o
o
o
allergies:
Codeine or other narcotics ....................................................................o
o
o
Are you allergic to or have you had a reaction to any of the following?
Metals ..................................................................................................o
o
o
If yes, please specify the type of reaction you had.
Latex (rubber) ......................................................................................o
o
o
Local anesthetics ..................................................................................o
Iodine ...................................................................................................o
o
o
o
o
Aspirin .................................................................................................o
Hay fever/seasonal allergies .................................................................o
o
o
o
o
Penicillin or other antibiotics................................................................o
Animals ................................................................................................o
o
o
o
o
Barbituates, sedatives, or sleeping pills ................................................o
Food .....................................................................................................o
o
o
o
o
Sulfa drugs ...........................................................................................o
Other ....................................................................................................o
o
o
o
o
yes No DK
yes No DK
Artificial (prosthetic) heart valve..........................................................o
o
o
Rheumatoid arthritis .........o o o
Epilepsy .............................o o o
Previous infective endocarditis .............................................................o
o
o
Systematic lupus
Hepatitis, jaundice,
Damaged valves in a transplanted heart ..............................................o
o
o
erythematosus ..............o o o
or liver disease ..............o o o
CONGENITAL HEART DISEASE (CHD)
Asthma .............................o o o
Fainting spells or seizures ..o o o
Unrepaired, cyanotic CHD .................................................................o
o
o
Bronchitis ..........................o o o
Neurological disorder ........o o o
Repaired completely in the last six months ......................................o
o
o
Emphysema ......................o o o
If yes, specify: _______________
Repaired CHD with residual defects..................................................o
o
o
Sinus trouble .....................o o o
Sleep disorder .................. o o o
Except for the conditions listed above, antibiotic prophylaxis
Tuberculosis ......................o o o
Mental health disorder .....o o o
is no longer recommended for any other form of CHD.
Cancer/chemotherapy/
If yes, specify: _______________
radiation treatment ......o o o
Recurrent infections ..........o o o
yes No DK
yes No DK
Chest pain upon exertion ..o o o
If yes, specify: _______________
Cardiovascular disease ..... o o o
Pacemaker ....................... o o o
Chronic pain ......................o o o
Kidney problems
o o o
Angina ............................. o o o
Rheumatic fever ............... o o o
Diabetes - Type I or II .........o o o
Night sweats .....................o o
o
Congestive heart failure ... o o o
Rheumatic heart disease .. o o o
Eating disorder ..................o o o
Osteoporsis .......................o o
o
Damaged heart valves ..... o o o
Abnormal bleeding .......... o o o
Malnutrition ......................o o o
Persistent swollen glands
Heart attack ..................... o o o
Anemia ............................ o o o
Gastrointensinal disease ...o o o
in neck ..........................o o
o
Heart murmur .................. o o o
Blood transfusion ............. o o o
G.E.Reflux/persistent
Severe headaches or
Low blood pressure .......... o o o
If yes, date: _______________
heartburn .....................o o o
migraines ......................o o o
High blood pressure ......... o o o
Hemophilia ...................... o o o
Ulcers ................................o o o
Severe/rapid weight loss ...o o o
Other congenital
AIDS or HIV infection ........ o o o
Thyroid problems ..............o o o
Sexually transmitted
heart defects ................ o o o
Arthritis............................ o o o
Stroke ................................o o o
disease ..........................o o o
Mitral valve prolapse ........ o o o
Autoimmune disease ....... o o o
Glaucoma ..........................o o o
Excessive urination ............o o o
Has a physician or previous dentist recommend that you take antibiotics prior to your dental treatment? ......................................................................................................o
o o
(
)
If yes, please provide the name and phone number: _______________________________________________________________________________
Do you have any disease, condition, or problem not listed above that you think should be disclosed? .............................................................................................................o
o o
If yes, please explain __________________________________________________________________________________________________
NOTE: Both dental staff and patient are encouraged to discuss any and all relevant patient health issues prior to treatment.
I certify that I have read and understand the above, and that the information given on this form is accurate. I understand the importance of a truthful health history and that the BCC staff will rely on this information
for treating me. I acknowledge that my questions, if any, about inquiries set forth above have been answered to my satisfaction. I will not hold BCC or any other member of the staff responsible
for any action they take or do not take because of errors or omissions that I may have made in the completion of this form.
/
/
Signature of patient/legal guardian: _________________________ Date: ____________Student signature: ________________________________Instructor: ________
/
/
Signature of patient/legal guardian: _________________________ Date: ____________Student signature: ________________________________Instructor: ________
/
/
Signature of patient/legal guardian: _________________________ Date: ____________Student signature: ________________________________Instructor: ________
For ComPletioN By iNstruCtor – Comments: ___________________________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________________________________________________________

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