ADA Forms HEALTH HISTORY FORM Today's Date: As required by law, our office adheres to written policies and procedures to protect the privacy of information about you that we create, receive or maintain. Your answers are for our records only and will be kept confidential subject to applicable laws. Please note that you will be asked some questions about your responses to this questionnaire and there may be additional questions concerning your health. This information is vital to allow us to provide appropriate care for you. This office does not use this information to discriminate. State:AL - AlabamaAK - AlaskaAZ - ArizonaAR - ArkansasCA - CaliforniaCO - ColoradoCT - ConnecticutDE - DelawareDC - District Of ColumbiaFL - FloridaGA - GeorgiaHI - HawaiiID - IdahoIL - IllinoisIN - IndianaIA - IowaKS - KansasKY - KentuckyLA - LouisianaME - MaineMD - MarylandMA - MassachusettsMI - MichiganMN - MinnesotaMS - MississippiMO - MissouriMT - MontanaNE - NebraskaNV - NevadaNH - New HampshireNJ - New JerseyNM - New MexicoNY - New YorkNC - North CarolinaND - North DakotaOH - OhioOK - OklahomaOR - OregonPA - PennsylvaniaRI - Rhode IslandSC - South CarolinaSD - South DakotaTN - TennesseeTX - TexasUT - UtahVT - VermontVA - VirginiaWA - WashingtonWV - West VirginiaWI - WisconsinWY - Wyoming Birth Date: Sex Male Female Do you have any of the following diseases or problems: Active Tuberculosis Persistent cough greater than a 3 week duration Cough that produces blood Been exposed to anyone with tuberculosis If you answer yes to any of the 4 items above, please stop and contact the receptionist. Dental Information Do your gums bleed when you brush or floss? Are your teeth sensitive to cold, hot, sweets or pressure? Does food or floss catch between your teeth? Is your mouth dry? Have you ever had periodontal(gum) treatement? Have you ever had orthodontic treatment? Have you had any problems associated with previous dental treatment? Is your home water supply fluoridated Do you drink bottled or filtered water? are you currently experiencing dental pain or discomfort? Do you have earaches or neck pains? Do you have any clicking, popping or discomfort in the jaw? Do you brux or grind your teeth? Do you have sores or ulcers in your mouth? Do you wear dentures or partials? Do you participate in active recreational activities? Have you ever had a serious injury to your head or mouth? Date of your last dental exam Date of last dental X-Rays Medical Information Are you now under the care of a physician? YesNo State:AL - AlabamaAK - AlaskaAZ - ArizonaAR - ArkansasCA - CaliforniaCO - ColoradoCT - ConnecticutDE - DelawareDC - District Of ColumbiaFL - FloridaGA - GeorgiaHI - HawaiiID - IdahoIL - IllinoisIN - IndianaIA - IowaKS - KansasKY - KentuckyLA - LouisianaME - MaineMD - MarylandMA - MassachusettsMI - MichiganMN - MinnesotaMS - MississippiMO - MissouriMT - MontanaNE - NebraskaNV - NevadaNH - New HampshireNJ - New JerseyNM - New MexicoNY - New YorkNC - North CarolinaND - North DakotaOH - OhioOK - OklahomaOR - OregonPA - PennsylvaniaRI - Rhode IslandSC - South CarolinaSD - South DakotaTN - TennesseeTX - TexasUT - UtahVT - VermontVA - VirginiaWA - WashingtonWV - West VirginiaWI - WisconsinWY - Wyoming Are you in good health? YesNo Date of last physical exam: Has there been any change in your general health within the past year? YesNo Have you had a serious illness, operation or been hospitalized in the past 5 years? YesNo Are you taking or have you recently taken any prescription or over the counter medicine(s)? YesNo Do you wear contact lenses? YesNo Have you had an orthopedic total joint (hip, knee, elbow, finger) replacement? YesNo Date: Are you taking or scheduled to begin taking either of the medications, alendronate (Fosamax®) or risedronate (Actonel®) for osteoporosis or Paget’s disease? YesNo Since 2001, were you treated or are you presently scheduled to begin treatment with the intravenous bisphosphonates (Aredia® or Zometa®) for bone pain, hypercalcemia or skeletal complications resulting from Paget’s disease, multiple myeloma or metastatic cancer? YesNo Date treatment began: Do you use controlled substances(drugs)? YesNo Do you use tobacco (smoking, snuff, chew, bidis)? YesNo If so, how interested are you in stopping? Select one: Very Somewhat Not interested Do you drink alcoholic beverages? YesNo WOMEN ONLY: Women, are you....: Pregnant Trying to get pregnant Nursing On birth control Are you allergic to or have you had a reaction to: Local Anesthetics Aspirin Penicillin or other antibiotics Barbiturates, sedatives, or sleeping pills Sulfa Drugs Codeine or other narcotics Metals Latex (Rubber) Iodine Hay fever/seasonal Animals Food Please check your response to indicate if you have had any of the following diseases or problems: Artificial (prosthetic) heart valve Previous infective endocarditis Damaged valves in transplanted heart Unrepaired, cyanotic CHD(Congenital heart disease) CHD Repaired (completely) in last 6 months Repaired CHD with residual defects Except for the conditions listed above, antibiotic prophylaxis is no longer recommended for any other form of CHD. Cardiovascular Disease Angina Arteriosclerosis Congestive heart failure Damaged heart valves Heart attack Heart murmur Low blood pressure High blood pressure Other congenital heart defects Mitral valve prolapse Pacemaker Rheumatic fever Rheumatic heart disease Abnormal bleeding Anemia Blood transfusion Hemophilia AIDS or HIV infection Arthritis Autoimmune Disease Rheumatoid arthritis Systemic lupus erythematosus Asthma Bronchitis Emphysema Sinus trouble Tuberculosis Cancer/Chemotherapy/Radiation treatment Chest pain upon exertion Chronic pain Diabetes Type I or II Eating disorder Malnutrition Gastrointestinal disease G.E. Reflux/persistent heartburn Ulcers Thyroid problems Stroke Glaucoma Hepatitis, jaundice or liver disease Epilepsy Fainting spells or seizures Neurological disorders Recurrent infections Kidney problems Osteoporosis Persistent swollen glands in neck Severe headaches/migraines Severe or rapid weight loss Sexually transmitted disease Excessive Urination Has a physician or previous dentist recommend that you take antibiotics prior to your dental treatment? YesNo Do you have any disease, condition, or problem not listed above that you think I should know about? YesNo NOTE: Both Doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment. I certify that I have read and understand the above and that the information given on this form is accurate. I understand the importance of a truthful health history and that my dentist and his/her staff will rely on this information for treating me. I acknowledge that my questions, if any, about inquiries set forth above have been answered to my satisfaction. I will not hold my dentist, or any other member of his/her staff, responsible for any action they take or do not take because of errors or omissions that I may have made in the completion of this form. Date: Submit Form Your request has been sent -- we will be in contact with you shortly. There was an error! Please phone our office.