HEALTH HISTORY
*All information given is considered confidential. No information will be released without expressed written consent.

Patient’s Name ____________________________________________________Date: ______________

Date of Birth: _____________ Daytime Phone: _________________Home Phone: ______________

What name would you prefer to be addressed by?____________________________________________

In case of an emergency, contact: ____________________________Telephone: _______________

Physician’s Name: __________________________________________ Telephone: _______________

Date of last physical examination: ______________

Are you under the care of a physician now or have you been within the last two years?     YES NO

Have you had surgery or been hospitalized within the last two years? YES NO
Reason for hospitalization: __________________________________________

Please list ALL medications you are CURRENTLY taking:

1.__________________       2.___________________ 3.___________________ 4.__________________

5.__________________       6.___________________ 7.___________________ 8.__________________

Please list ALL medications you are ALLERGIC to:

1. _________________       2.___________________ 3. ___________________ 4.__________________

Do you have a Latex Allergy? YES NO                   Do you have a Metal Sensitivity? YES NO

Please list ALL vitamins, herbal supplements or “cures” you are currently taking:
1. __________________ 2. __________________ 3. ___________________ 4. _________________

Have you ever had excessive bleeding requiring special treatment to control? YES      NO

Have you ever taken Redux or Pondimin (Fen Phen)? YES NO
If you have taken Redux or Pondimin, have you ever had a cardiac evaluation? YES           NO

For women: Are you pregnant now? YES         NO
Circle any of the following conditions/illnesses, which you currently have or have had in the past:

*Heart Murmur                   Anemia/Blood Disorder             Alcoholism
*Implant (heart valve, etc)     Stroke                            Drug Addiction
*Organ Transplant               Kidney Disease                    HIV or AIDS
*Joint Replacement              Jaundice/Liver Disease            Sexually Transmitted Disease
*Congenital Heart Problems      Ulcers                            Eye Problems
*Mitral Valve Prolapse          Mental Problems                   Birth Defects
Heart Failure/Attack/Disease    Emphysema/Lung Problems           Hepatitis A, B, C
Asthma                          Hemophilia                        Arthritis: osteoarthritis or rheumatoid
Angina                          Tuberculosis (TB)                 Seizures/Epilepsy
High Blood Pressure             Sinus Problems                    Canker/Cold Sores
Rheumatic Fever                 Hay Fever/Allergies               Fainting or Dizzy Spells
Heart Pacemaker                 Diabetes                          Sickle Cell Disease
Cancer: type _____________      Chemotherapy                      Radiation Treatment
Thyroid Problems/Disease        Heart Surgery                     Anything Not Listed Above: _____________________

Do you require premedication with an antibiotic for your dental treatment? YES _____ NO _____
Do you take a blood thinner? YES _____ NO _____
Do you use tobacco? YES NO            If so, what type: Cigarettes, Cigars, Pipe, Chew
How often to you use tobacco? __________________________________________________________________

Patient/Parent Signature: ________________________________________________ Date; ________________
                                    **Please see reverse side of this form**

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