Briarwood Sedation-Dentistry-Consent-Medical-History

HEALTH HISTORY

Name*

Date*

Date of last health care exam:*

What was this exam for?*

Have you been hospitalized in the last 5 years?*

No
Yes

If yes, reason:*

Are you currently receiving care?*

No
Yes

If 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)*

No
Yes

Psychosis*

No
Yes

Anemia*

No
Yes

Sore/Enlarged Lymph Nodes*

No
Yes

Diabetes*

No
Yes

Previous Biopsies*

No
Yes

Epilepsy*

No
Yes

Slow-Healing Mouth Sores*

No
Yes

Hepatitis, Any Form*

No
Yes

Other Infections*

No
Yes

Rheumatic Fever*

No
Yes

Recurrent Illness*

No
Yes

Asthma*

No
Yes

Joint Replacement*

No
Yes

HIV Positive or AIDS Related Complex*

No
Yes

Glaucoma*

No
Yes

Emphysema or other Respiratory Illness*

No
Yes

Abnormal Bleeding from a Cut*

No
Yes

Abnormal Heart Condition*

No
Yes

Liver Disease (including Jaundice)*

No
Yes

Kidney Disease*

No
Yes

Unintentional Weight Loss/Gain*

No
Yes

Heart (Surgery, Disease, Attack)*

No
Yes

Latex Sensitivity*

No
Yes

Venereal Disease*

No
Yes

H.I.V. Infection/AIDS*

No
Yes

Are you required to Pre-medicate before dental treatment?*

No
Yes

Women:

Are you pregnant?

No
Yes

If no, are you planning a pregnancy in the near future?

No
Yes

Are you a nursing mother?

No
Yes

Are you taking birth control pills?

No
Yes

Do you have abnormal blood pressure?

No
Yes

If yes, what is it usually?

Are you allergic or have you had a reaction to:

a. Local anesthetics*

No
Yes

b. Penicillin or other antibiotics

No
Yes

c. Aspirin

No
Yes

d. Codeine, valium, or other sedatives

No
Yes

e. Other

Are you a smoker?*

No
Yes

If so, how much do you smoke per day?

Do you use CBD in any form?*

No
Yes

If yes, how often?

Do you use marijuana?*

No
Yes

If yes, how often?

Do you consume grapefruit juice, grapefruits or grapefruit extract?*

No
Yes

Please list any medications you are currently taking.

Are you taking Tagamet (Cimetidine)?*

No
Yes

If yes, how often?

Do you take Antacids?*

No
Yes

If yes, how often?

Are you taking any herbal supplements/medicines?*

No
Yes

If yes, which ones?

Weight:*

Diet:

Restricted Diet

How many meals a day*

Food Allergies

Sugar in your diet:

None
Slight
Moderate
High

Doctor's Use only

Comments 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*

Doctor

Doctor Signature

Date