Download Heart/Blood Vessels - Twain Harte Family Dental Care

Twain Harte
Family Dental Care
A Professional Dental Corporation
Health History Questionnaire (Confidential)
Patient Name_________________________________________
Date______________________________
Physicians Name____________________________________Phone #________________________
1.
2.
Have you (has the patient) ever had any health problem in the past five (5) years?…………… Yes
No
Have you (has the patient) seen a doctor (MD or DO) in the past five (5) years?………........… Yes
No
If yes, for what reason?__________________________________________________________________
3.
Have you (has the patient) been in the hospital in the past (5) five years?……………………. Yes
No
If yes, for what reason?_________________________________________________________________
_______________________________________________________________________
______________________________________________________________________
4.
Have you (has the patient) had a serious illness in the past five (5) years?…………………….. Yes
No
If yes, what illness?____________________________________________________________________
______________________________________________________________________
5.
Is there any activity your doctor says you (the patient) cannot do?……………………………. Yes
No
If yes, what?__________________________________________________________________________
_______________________________________________________________________
6.
Have you (has the patient) ever had a bleeding problem?……………………………………… Yes
No
Please circle the appropriate response for the following questions.
Heart/Blood Vessels
Rheumatic fever……………. Yes
Rheumatic heart disease……. Yes
Heart valve damage…………Yes
Heart murmur………………. Yes
Congenital heart defect…….. Yes
Artificial heart valve…….…. Yes
High blood pressure……..…. Yes
Heart attack……………...…. Yes
TIA / Stroke………………. Yes
Heart surgery………………. Yes
Angioplasty……………...…. Yes
Vascular surgery………...…. Yes
Pacemaker……………….…. Yes
Coronary heart disease…..…. Yes
Congestive heart failure……. Yes
Angina pectoris………….…. Yes
Chest pain………………...…Yes
Irregular heart beat…………. Yes
Rapid heart beat……………. Yes
Other heart / vessel disorder.. Yes
Blood
Blood clots or thrombosis..… Yes
Anemia…………………...… Yes
Sickle cell disease / trait….…Yes
Hemophilia……………….…Yes
Bleeding disorder………...… Yes
Bruise easily for no
apparent reason………..… Yes
Other blood disorder……..… Yes
Nervous System
Epilepsy……………………..Yes
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Seizure disorder……………. Yes
Multiple sclerosis……..……..Yes
Trigeminal neuralgia……..…..Yes
Psychiatric treatment……….. Yes
Psychological counseling….. Yes
Persistent numbness/tingling...Yes
Other nervous system disorder. Yes
Head & Neck
Glaucoma……….……….…..Yes
Chronic sinusitis………….… Yes
Injury to head,
neck, face, teeth…………….Yes
Headaches……………….…..Yes
Unexplained visual change….Yes
Frequent or severe
nosebleeds…………..…….. Yes
Persistent sore throat
or hoarseness………..……...Yes
Difficulty swallowing…..…...Yes
Other head / neck disorder......Yes
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Endocrine
Diabetes Type I or II……….. Yes
Low thyroid…………….…... Yes
Other thyroid condition….…..Yes
Cushing’s syndrome…….….. Yes
Parathyroid condition..…..…..Yes
Pituitary condition……….…..Yes
Other endocrine condition….. Yes
No
No
No
No
No
No
No
No
Musculoskeletal
Sjogren’s syndrome……….... Yes
No
No
No
No
No
No
Arthritis……………..……...Yes
Artificial joint………..……..Yes
Fibromyalgia/rheumatism…...Yes
Chronic back pain…………..Yes
Other bone/muscle disorder... Yes
No
No
No
No
No
Respiratory
Tuberculosis……………….. Yes
Asthma…………………….. Yes
Chronic bronchitis…………..Yes
Emphysema……..………….. Yes
Persistent cough……...…….. Yes
Cough up bloody sputum….. Yes
Shortness of breath……..….. Yes
Other respiratory……..…….. Yes
No
No
No
No
No
No
No
No
Urinary Tract
Kidney disease……….…….. Yes
Renal dialysis………...…….. Yes
Venereal disease……..…….. Yes
Sexually transmitted disease...Yes
Other urinary disorder.…….. Yes
No
No
No
No
No
Digestive System
Hepatitis…………...……….. Yes
Liver disease……………….. Yes
Cirrhosis of the liver……….. Yes
Ulcers…………...………….. Yes
Jaundice……………………..Yes
Frequent heartburn…...…….. Yes
GERD………………...…….. Yes
Acid reflux…………………..Yes
Frequent nausea/vomiting…...Yes
Other digestive disorder……. Yes
No
No
No
No
No
No
No
No
No
No
Cancer History
Leukemia……………..……..Yes
Benign tumors/growths…….. Yes
No
No
Cancer………………..…….. Yes
No
If yes, what type:
If yes, treatment:
[ ] Surgery
[ ] Radiation
[ ] Chemotherapy
[ ] Hormone therapy
Other cancer………..…….. Yes
Allergy History
Are you allergic to or have you ever
had a bad reaction to the following:
Dental anesthetics…....…….. Yes
Penicillin……………..…….. Yes
Sulfa drugs…………...…….. Yes
Other antibiotics……...…….. Yes
Aspirin……………….…….. Yes
Latex products………..……..Yes
Metals / jewelry……....……..Yes
Other allergy……..…..…….. Yes
Anything else that
runs in the family? …...…….. Yes
No
If yes, describe______________________
Miscellaneous
Lupus erythematosus……....... Yes
Organ transplant………..…….Yes
If yes, which organ? ……..…..Yes
Suppressed immune system.... Yes
Persistent fever………….…….Yes
Taken steroids………..…..…..Yes
Taken prednisone / cortisone...Yes
Taken prescription diet pills.... Yes
If yes, which?
[ ] Pondimin
[ ] Redux
[ ] Phen-phen
[ ] Other
Have you, or are you currently
taking Fosamax or similar
bisphosphonate medication..….Yes
Use/used tobacco products...…Yes
Smoke………………..…..….. Yes
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Used recreational drugs (cocaine, crack,
heroine, speed etc)……….....Yes
No
If yes, what type?____________________
Are you a recovering
alcoholic or addict? ...…….. Yes
No
Other
Down syndrome……………. Yes
Developmental delay………. Yes
Mental retardation…………. Yes
Cerebral palsy……………… Yes
Autism……………………… Yes
ADHD……………………… Yes
Combative / aggressive…..... Yes
Self-abusive…………………Yes
Surgical:
VP shunt or revisions……. Yes
Vagal nerve stimulator…… Yes
Blood transfusion………… Yes
No
No
No
No
No
No
No
No
No
No
No
When? _________________________
No
No
No
How many packs per day?
How long?
Women Only
Are you pregnant? ……...….. Yes
Is there a chance you
could be pregnant? ……….. Yes
Are you nursing
(breast-feeding)? .…..…….. Yes
Are you taking birth
control pills?...........................Yes
Family History
Has anyone in your family (grandparents,
parents, siblings, children) ever had:
Chew tobacco…………..….....Yes
No
Diabetes? …………….…….. Yes
No
Heart disease? ……….…….. Yes
No
Drink alcoholic beverages…....Yes
No
Depression/anxiety? ……….. Yes
No
If yes, how much?___________________
Tuberculosis? …………..….. Yes
No
Bleeding disorder? ……….... Yes
No
Circle the following drugs that you are (the patient is) taking or have taken
Heart pills
Oral contraceptive
Nitroglycerin
Steroids/Cortisone
Digitals
Hormones
Aspirin
Insulin
Blood thinners
Diabetic drugs
Blood pressure
Thyroid
List all medications and doses that you are (the patient is) now taking:
No
No
No
No
Antibiotics
Antihistamines
Cyclosporine A
Tranquilizers
Sleeping pills
Antidepressants
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I UNDERSTAND THAT THE INFORMATION THAT I HAVE GIVEN TODAY IS CORRECT TO THE BEST OF MY KNOWLEDGE. I ALSO UNDERSTAND THAT THIS INFORMATION WILL
BE HELD IN THE STRICTEST CONFIDENCE, AND IT IS MY RESPONSIBILITY TO INFORM THE OFFICE OF ANY CHANGES IN MY MEDICAL OR DENTAL STATUS.
I AUTHORIZE THE DENTAL STAFF TO PERFORM ANY NECESSARY DENTAL SERVICES THAT I MAY NEED DURING DIAGNOSIS AND TREATMENT WITH MY INFORMED CONSENT.
Name of person filling out form
If you are not the patient, are you
able to give legal consent for the patient?
Relationship to patient
Yes
No
If “No,” who does?
Name of person able to give consent
Signature of parent / guardian / person filling our form
Date
________________________________________________________________________
Signature of dentist (I verbally reviewed the medical information above with the patient)
______________________________________________________
Date