Microsoft word - health history


Answer all questions by circling Yes (Y) or No (N)
All responses are kept confidential
G. Insulin or Oral Anti-Diabetic drugs? .Y N 4. Are you now under a physician’s care for H. Digitalis, Inderal, Nitroglycerin or other heart 5. Have you ever had any serious il nesses,
operations or hospitalizations? If so, describe:.Y N J. Any regular medicine, pil s or drugs – either over-the-counter or prescription. If Yes, please .Y N 7. DO YOU HAVE OR HAVE YOU EVER HAD:
____________________________________________ A. Rheumatic Fever or Rheumatic Heart Disease?.Y N ____________________________________________ C. Cardiovascular Disease (Heart Attack, Heart 9. ARE YOU ALLERGIC TO OR HAVE YOU HAD AN
Trouble, Heart Murmur, Coronary Artery Disease, ADVERSE REACTION TO:
Angina, High Blood Pressure, Stroke, Palpitations, A. Local Anesthesia (Novocain, etc.)? .Y N B. Penicil in or other antibiotics? .Y N D. Lung Disease (Asthma, Emphysema, Chronic Cough, Bronchitis, Pneumonia, Tuberculosis, E. Seizures, Convulsions, Epilepsy, Fainting, G. Other al ergies or reactions? Please, list.Y N Dizziness, Psychiatric Treatment, or other F. Bleeding Disorder, Anemia, Bleeding Tendency, Blood Transfusion? Do you bruise easily?.Y N G. Liver Disease (Jaundice, Hepatitis)?.Y N 11. Is there any past history of Alcohol or Chemical Dependency or Emotional Disorder that may affect 12. Have you had any serious problems associated with 13. Have you or an immediate family member had any problem associated with intravenous anesthesia?.Y N N. Implants placed anywhere in your body 14. Do you have any other disease, condition or (Heart Valve, Pacemaker, Hip, Knee)? .Y N problem not listed above that you think the doctor O. Radiation (X-ray) treatment for Cancer? .Y N P. Clicking or popping of jaw joint, pain near ear, 15. Do you wish to talk to the doctor privately difficulty opening mouth, grind or clench teeth?.Y N 16. FOR WOMEN ONLY
R. Any disease, drug or transplant operation A. Are you Pregnant, or is there any chance
that has depressed your immune system? .Y N B. If you are using Oral Contraceptives, it is
important that you understand that antibiotics (and some other medications) may interfere with B. Anticoagulants (Blood Thinners)? .Y N the effectiveness of oral contraceptives. C. Aspirin or drugs such as Motrin, Aleve, Ibuprofen?.Y N Therefore, you wil need to use mechanical forms of birth control for one complete cycle of birth control pil s, after the course of antibiotics or other medication is completed. Please consult with your physician for further guidance. I understand the importance of a truthful Health History to assist the doctor in providing the best care possible. I have had the
opportunity to discuss my Heath History with my doctor.
Signature of Person Completing Health History
Medical Update: I have ready my Health History dated
and confirm that it adequately states past and present



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Nhs qipp medicines management implementation august 2010

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