General Health Chart printable pdf download

GENERAL HEALTH CHART

Please Complete and Return

Name __________________ Address_______________________ City _________________ State _____

Zip Code _________ Home Phone____________Bus. Phone ____________ Date of Birth __________

Employer ________________ Occupation ________________ Insurance Co._____________________

SS# _______________________ Group# ___________________________

Spouse’s name ___________________ Spouses’ Employer _____________ Occupation __________

Spouse’s Ins. Co. __________ Spouse’s SS# _________________Spouse’s Group# _______________

Dentist ____________________________________ Physician ____________________________________

Since the cause of periodontal disease is a combination of many factors, and very complex, it is necessary to root

out any possible causative factor. The success of the treatment depends upon this.

Although many of these questions may seem to have nothing to do with your gum condition, they are all related to

possible contributing influences.

In the following questions, circle “yes” or “no”, whichever applies. Your answers are for our records only and will be

considered confidential.

1. Are you in good health? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .YES

A. Has there been any change in your general health in the past year? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .YES

If answer is yes, what was the change? _____________________________________________________________

2. When was your last physical exam? __________________________________________________________________

3. Are you now under the care of a physician? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . YES

If answer is yes, what condition is being treated _________________________________________________________

4. Have you had any serious illness or operation? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . YES

5. Have you been hospitalized or had a serious illness in the past five years? . . . . . . . . . . . . . . . . . . . . . . . . . . . YES

If answer is yes, for what problem? ____________________________________________________________________

6. Do you have or have you had any of the following diseases or problems?

a. Rheumatic fever or rheumatic heart disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . YES

b. Congenital heart lesions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . YES

c. Cardiovascular disease (heart trouble, heart attack, coronary artery insufficiency, coronary occlusion,

arteriosclerosis, stroke, heart murmur, or mitral valve prolapse). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . YES

1. Do you have chest pains upon exertion? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . YES

2. Do you have shortness of breath after mild exercise? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . YES

3. Do your ankles swell? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . YES

4. Do you get short of breath when you lie down, or do you require extra pillows when you sleep?. . . . . . . YES

5. Do you have a cardiac pacemaker? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . YES

6. Do you have artificial joints or valves? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . YES

7. Do you have high blood pressure? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . YES

d. Allergy? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . YES

e. Sinusitis? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . YES

f. Asthma or hay fever? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . YES

g. Hives or a skin rash? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . YES

h. Fainting spells or seizures? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . YES

Diabetes? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . YES

1. Do you have to urinate more than 6 times a day? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . YES

2. Are you thirsty much of the time? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . YES

3. Does your mouth frequently become dry? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . YES

Hepatitis, jaundice or liver disease? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . YES

k. Arthritis? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . YES

Inflammatory rheumatism (painful swollen joints)? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . YES

m. Low blood pressure? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . YES

n. Herpes virus (cold sores)? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . YES

o. Stomach ulcers? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . YES

p. Kidney trouble?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . YES

q. Tuberculosis? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . YES

r. Venereal Disease? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . YES

s. Acquired Immune Deficiency Syndrome? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . YES

7. Have you had abnormal bleeding associated with previous extractions, surgery or trauma? . . . . . . . . . . . . . . . YES

8. Do you have any blood disorder, such as anemia? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . YES

9. Have you had surgery or x-ray treatment for a tumor, growth or other condition of your head or neck?. . . . . . . YES

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