Microsoft word - health history 2010 - edited .doc

PATIENT MEDICAL HISTORY
1. Are you currently being treated by your physician for any medical condition? ____________________ ________________________________________________________________________________ 2. Physician’s Name _________________________________ 3 .Please list ALL medications you are currently taking: ______________________________________ _________________________________________________________________________________ 4. Please circle any illness you have ever had: heart valve replacement high blood pressure joint replacement allergies to medicine heart murmur heart trouble infectious hepatitis sinus problems mitral valve prolapse anemia tuberculosis asthma rheumatic fever diabetes epilepsy/seizures AIDS (HIV) psychological glaucoma kidney/liver thyroid Crohn's disease irritable bowel/colitis TMJ/TMD 5. Has a dentist or a physician ever told you that you need to take antibiotics before dental appointments for a medical condition ? No …. Yes … If yes, have you taken them today? No…. Yes…. What did you take?___________________ How much?____________ 6. Have you had knee, hip or other joint replacement? No… Yes ……. If so, when?_______________ 7. Have you ever taken any diet drugs such as Pondimin (fenfluramine), Redux (dexphenfluramine) or Phen-fen (fenfluramine-phentermine combination)? No… Yes…. If so, when? ___________ Have you seen your physician about this? No… Yes…… If so, when ?___________ 8. Do you wear a pacemaker? No…. Yes…. 9. Have you ever had trouble with prolonged bleeding after surgery? No…. Yes…. 10 . Do you take blood thinners such as Plavix (clopidoqrel), Coumadin (warfarin), Asprin ? N o… Yes. 11. Are you currently taking or have you taken bisphophonate medications, such as Actonel, Fosamax or Zometa, within the past 12 years? No…. Yes……. If so, which one? _______________ 12. Please circle any of the medications or substances listed below to which you have had an unusual reaction: Penicillin Clindamycin (Cleocin) Ibuprofen/Advil/Motrin Codeine Latex Aspirin Adrenaline (Epinephrine) Tylenol Sulfa Novocaine Erythromycin Others : please list below _____________________________________________________________________________ 12. Is there any other information that we should be know about your health? Any chronic conditions? ____________________________________________________________________________ 13. Is there any information that you would like to tell us about previous dental appointments? _______________________________________________________________________________ I certify that the above information is correct to the best of my knowledge. I understand that providing incorrect information can be dangerous to my health. I will not hold Endodontic Associates, LTD or any members of their dental team responsible for errors or omissions that I have made in completion of this form It is my responsibility to notify my dentist of any changes in the above medical status. Patient or Responsible Party Signature:____________________________________________ Date:______________________ Attending Doctor:_______________________________

Source: http://www.springfieldendo.com/clinic/springfieldendo/forms/Health_History_2010-edited.pdf