General Health Chart Page 2

ADVERTISEMENT

10. Have you ever had a blood transfusion? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . YES
NO
If so, explain: ___________________________________________________________________________
11. Have you ever had or are you currently taking kidney dialysis? . . . . . . . . . . . . . . . . . . . . . . . . . . YES
NO
If so, explain: ___________________________________________________________________________
12. Are you taking any of the following:
a. Antibiotics or sulfa drugs? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . YES
NO
b. Anticoagulants (blood thinners)? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . YES
NO
c. High blood pressure medication? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . YES
NO
d. Cortisone (steroids)?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . YES
NO
e. Tranquilizers? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . YES
NO
f. Aspirin?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . YES
NO
g. Insulin, Tolbutamide (Orinase) or similar drug? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . YES
NO
h. Digitalis or drugs for heart trouble? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . YES
NO
i.
Nitroglycerin? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . YES
NO
j.
Antihistamine? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . YES
NO
k. Oral contraceptive or other hormonal therapy? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . YES
NO
13. Are you taking any other drug or medication not mentioned above? . . . . . . . . . . . . . . . . . . . . . . YES
NO
If so, specify: ___________________________________________________________________________
14. Are you allergic or have you reacted adversely to:
a. Local anesthetics, novacaine? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . YES
NO
b. Penicillin or other antibiotics? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . YES
NO
c. Sulfa drugs? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . YES
NO
d. Barbiturates, sedatives, or sleeping pills? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . YES
No
e. Aspirin?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . YES
NO
f. Iodine? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . YES
NO
g. Codeine or other narcotics? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . YES
NO
h. Other _______________________________________________________________________________
15. Are you employed in any situation which exposes you regularly to x-rays or other ionizing
radiations? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . YES
NO
16. Are you wearing contact lenses? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . YES
NO
17. Have you ever been treated for Glaucoma? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . YES
NO
18. WOMEN - Are you pregnant?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . YES
NO
— DENTAL —
19. Have you had any serious trouble associated with any previous dental treatment? . . . . . . . . . . . YES
NO
20. Have you ever had an acute sore mouth? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . YES
NO
21. Do your gums bleed? When? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . YES
NO
22. Are you aware of a bad taste or odor in your mouth? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . YES
NO
23. Are you troubled with frequent gum boils? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . YES
NO
24. Does your jaw ever get “out of joint”?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . YES
NO
25. Do you ever have pain opening or closing your mouth? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . YES
NO
26. Did you ever wear braces for straightening your teeth? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . YES
NO
27. Have you ever had previous gum treatments? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . YES
NO
28. Have you ever smoked? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . YES
NO
29. Are you presently smoking? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . YES
NO
— INITIAL MEDICAL HISTORY —
1. ______________________________________________________________________________________
(DATE)
(PATIENT OR GUARDIAN SIGNATURE)
(HYGIENIST/ASSISTANT SIGNATURE)
— UPDATE OF MEDICAL HISTORY —
2. ______________________________________________________________________________________
(DATE)
(CHANGES)
______________________________________________________________________________________
______________________________________________________________________________________
(PATIENT OR GUARDIAN SIGNATURE)
(HYGIENIST/ASSISTANT SIGNATURE)
3. ______________________________________________________________________________________
(DATE)
(CHANGES)
______________________________________________________________________________________
______________________________________________________________________________________
(PATIENT OR GUARDIAN SIGNATURE)
(HYGIENIST/ASSISTANT SIGNATURE)

ADVERTISEMENT

00 votes

Related Articles

Top 20 Happy Easter Cards And Gift Tags To Download For Free
Top Ten Easter Arts And Crafts Activities For Your Kids
Free Easter Coloring Pages And Easter Printables For Your Kids

Related forms

General Health Questionnaire Template General Health Questionnaire Template Life
General Health Care Plan Form - Mukwonago Area School District - Wisconsin (2015) General Health Care Plan Form - Mukwonago Area School District - Wisconsin (2015) Medical
Dental Expense Claim - Metlife - Lancaster General Health Dental Expense Claim - Metlife - Lancaster General Health Business
Advance Healthcare Directive Form - Lancaster General Health Advance Healthcare Directive Form - Lancaster General Health Medical
School Entrance & General Health Exam Form/ Lhsaa Medical History Evaluation - Louisiana School Entrance & General Health Exam Form/ Lhsaa Medical History Evaluation - Louisiana Medical
Lancaster General Health Fitness For Duty Form - 2011 Lancaster General Health Fitness For Duty Form - 2011 Business
Student Flu Vaccine Consent Form - Delaware General Health District Student Flu Vaccine Consent Form - Delaware General Health District Legal
Paul Malone Boys Suits And Tuxedos General Size Chart Paul Malone Boys Suits And Tuxedos General Size Chart Life
Baby Doll Tee General Sizing Chart Baby Doll Tee General Sizing Chart Life
Nikegolf Nike Men's General Size Chart Nikegolf Nike Men's General Size Chart Life

Related Categories

Parent category: Medical
Download
Go
Page of 2