Health history

Name _________________________________ Social Security # ______-______-______ Sex _____ D.O. B. ___________________ Spouse or parent (if applicable) _______________________________ Employer __________________________________________ Home address _____________________________________________ City _______________ State _____ Zip _________________ Phone: Home (_____) _______-_______________ Work (_____) ______-_____________ Cell (_____) ______-_____________ 1. Is there any condition in your mouth, head, or neck causing you discomfort or swelling? . . . . . . . . . . . . . . . . . . . . . . . . . . . yes 2. Are you under a physician’s (doctor’s) care now? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . yes Doctor _________________________________ Reason ________________________________________ 3. Are you taking any medications at this time? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . yes no List ____________________________________________________________________________________ 4. Have you ever had a bleeding problem that needed medical treatment? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . yes 5. Have you ever been diagnosed with a heart murmur, heart defect, or have a pacemaker? . . . . . . . . . . . . . . . . . . . . . . . . . . . . yes 6. Have you ever had surgery, x-ray treatment, or been hospitalized or any major illness or injury? . . . . . . . . . . . . . . . . . . . . . . yes 7. Do you use tobacco? If so, what kind? __________________________ How often? ______________________________ yes 8. Are you pregnant? If so, how many months? _____________________________________________________________ yes 9. Do you have any artificial joints (hip, knee, elbow) or artificial heart valves? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . yes 10. Are you currently taking or have you ever taken a bisphosphonate medication such as Fosamax, Zometa, Actonel, Boniva, Aredia, Bonefos, Ostac, Skilid, Didronel? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . yes 11. Have you ever had any of the following diseases? (please circle) 12. Do you have any allergies (medication, latex, etc.)? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . yes 13. Do you have any reason to believe you have been exposed to AIDS or HIV? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . yes 14. Do you have any sores in your mouth that do not heal? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . yes 15. Is there any other information about your health we should know prior to treatment? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . yes List ______________________________________________________________________________________________ 16. Do you have dental insurance? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . yes Primary Insurance Company __________________________________________________________________________ Subscriber name ____________________________ D.O. B. ___________________ ID# ____________________ Secondary Insurance Company ________________________________________________________________________ Subscriber name ____________________________ D.O. B. ___________________ ID# ____________________
These answers I have given are true to the best of my knowledge. I am indicating my consent for routine dental procedures such as x-rays,
cleaning, fillings, crowns, and local anesthesia by signing below.
Patient or Parental consent _______________________________________________ Date ______________________

Source: http://nathanlukesdds.com/pdf/health_history.pdf