HEALTH HISTORYName*Date* Date Format: MM slash DD slash YYYY Date of last health care exam:* Date Format: MM slash DD slash YYYY What was this exam for?*Have you been hospitalized in the last 5 years?*NoYesIf yes, reason:*Are you currently receiving care?*NoYesIf yes, nature of care:Please list all the names and phone numbers of the physicians who are currently providing your care:*For the following questions select yes or no. Your answers are for our records only and are confidential. Please note that during your initial visit you will be asked some questions about your responses. Our team may ask additional questions concerning your health.Heart Murmur (mitral valve prolapse)*NoYesPsychosis*NoYesAnemia*NoYesSore/Enlarged Lymph Nodes*NoYesDiabetes*NoYesPrevious Biopsies*NoYesEpilepsy*NoYesSlow-Healing Mouth Sores*NoYesHepatitis, Any Form*NoYesOther Infections*NoYesRheumatic Fever*NoYesRecurrent Illness*NoYesAsthma*NoYesJoint Replacement*NoYesHIV Positive or AIDS Related Complex*NoYesGlaucoma*NoYesEmphysema or other Respiratory Illness*NoYesAbnormal Bleeding from a Cut*NoYesAbnormal Heart Condition*NoYesLiver Disease (including Jaundice)*NoYesKidney Disease*NoYesUnintentional Weight Loss/Gain*NoYesHeart (Surgery, Disease, Attack)*NoYesLatex Sensitivity*NoYesVenereal Disease*NoYesH.I.V. Infection/AIDS*NoYesAre you required to Pre-medicate before dental treatment?*NoYesWomen:Are you pregnant?NoYesIf no, are you planning a pregnancy in the near future?NoYesAre you a nursing mother?NoYesAre you taking birth control pills?NoYesDo you have abnormal blood pressure?NoYesIf yes, what is it usually?Are you allergic or have you had a reaction to:a. Local anesthetics*NoYesb. Penicillin or other antibioticsNoYesc. AspirinNoYesd. Codeine, valium, or other sedativesNoYese. OtherAre you a smoker?*NoYesIf so, how much do you smoke per day?Do you use CBD in any form?*NoYesIf yes, how often?Do you use marijuana?*NoYesIf yes, how often?Do you consume grapefruit juice, grapefruits or grapefruit extract?*NoYesPlease list any medications you are currently taking.Are you taking Tagamet (Cimetidine)?*NoYesIf yes, how often?Do you take Antacids?*NoYesIf yes, how often?Are you taking any herbal supplements/medicines?*NoYesIf yes, which ones?Weight:*Diet:Restricted DietHow many meals a day*Food AllergiesSugar in your diet: None Slight Moderate High Doctor's Use onlyComments on patient interview concerning medical history:Significant findings from questionnare or oral interview:Dental management considerations:I understand that above information is necessary to provide me with dental care in a safe and efficient manner. I have answered all questions to the best of my knowledge. Should further information be needed, I will notify the doctor of change in my health and medication. Patient*Patient Signature*Date* Date Format: MM slash DD slash YYYY DoctorDoctor SignatureDate Date Format: MM slash DD slash YYYY
