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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 ______________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________ 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