Download Heart/Blood Vessels - Loma Linda University School of Dentistry

Loma Linda University Special Care Dentistry
Health History Questionnaire (Confidential)
1.
2.
Have you (has the patient) ever had any health problem in the past five (5) years?…………… Yes
Have you (has the patient) seen a doctor (MD or DO) in the past five (5) years?………...… Yes
No
No
3.
If yes, for what reason?
Have you (has the patient) been in the hospital in the past (5) five years?……………………. Yes
No
4.
If yes, for what reason?
Have you (has the patient) had a serious illness in the past five (5) years?…………………….. Yes
No
5.
If yes, what illness?
Is there any activity your doctor says you (the patient) cannot do?……………………………. Yes
No
6.
If yes, what?
Have you (has the patient) ever had a bleeding problem?……………………………………… Yes
No
Please circle the appropriate response for the following questions.
He art/Blood Vessels
Rheumatic fever…………….
Rheumatic heart disease…….
Heart valve damage…………
Heart murmur……………….
Congenital heart defect……..
Artificial heart valve……….
High blood pressure……….
Heart attack……………….
T IA / Stroke……………….
Heart surgery……………….
Angioplasty……………….
Vascular surgery………….
Pacemaker……………….
Coronary heart disease…….
Congestive heart failure…….
Angina pectoris…………….
Chest pain…………………
Irregular heart beat………….
Rapid heart beat…………….
Other heart / vessel disorder.
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
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
Ne rvous System
Epilepsy…………………….. Yes
Seizure disorder……………. Yes
Multiple sclerosis………….. Yes
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
T rigeminal neuralgia……..… Yes
Chronic pain……………….. Yes
Anxiety/depression……….. Yes
Alzheimer’s disease……….. Yes
Dementia…………………… 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, teet h……………..
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
Endocrine
Diabetes T ype 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
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Musculoskeletal
Sjogrens syndrome……….. Yes
Arthritis…………………….. Yes
Artificial joint…………….. Yes
Fibromyalgia/rheumatis...….. Yes
Chronic back pain………….. Yes
Other bone/muscle disorder... Yes
No
No
No
No
No
No
Respiratory
T uberculosis……………….. Yes
Asthma…………………….. Yes
Chronic bronchitis………….. Yes
Emphysema……..………….. Yes
Persistent cough……...…….. Yes
Cough up bloody sputum….. Yes
Shortness of breath……..….. Yes
Other respiratory……..…….. Yes
Sleep apnea………………….Yes
No
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
Digestive System
Hepatitis…………...………..
Liver disease………………..
Cirrhosis of the liver………..
Ulcers…………... …………..
Jaundice……………………..
Frequent heartburn…...……..
GERD………………... ……..
Acid reflux
Frequent nausea/vomiting
Other digestive disorder
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
No
No
No
Cancer History
Leukemia…………….. …….. Yes
Benign tumors/growths…….. Yes
Cancer……………….. …….. Yes
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
Family History
Has anyone in your family (grandparents,
parents, siblings, children) ever had:
Diabetes? ……………. …….. Yes
No
Heart disease? ……….…….. Yes
No
Depression/anxiety? ……….. Yes
No
T uberculosis? ………….. ….. Yes
No
Bleeding disorder? ……….... Yes
No
Anything else that
runs in the family? ……….. Yes
No
No
No
No
Miscellaneous
Lupus erythematosus……..... Yes
Organ transplant……………. Yes
If yes, which organ? ……….. Yes
Suppressed immune system.. Yes
Persistent fever………..……..
Yes
T aken steroids………..…….. Yes
T aken prednisone / cortisone.Yes
T aken prescription diet pills.. Yes
If yes, which?
[ ] Pondimin
[ ] Redux
[ ] Phen-Fen
[ ] Other
Use/used tobacco products… Yes
Smoke……………….. …….. Yes
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Chew tobacco…………..….. Yes
Drink alcoholic beverages….. Yes
If yes, how much? …..…….. Yes
Used methamphetamines.…..Yes
Used amphetamine or speed.. Yes
Used cocaine or “crack” ..…..Yes
Used other recreational drug..Yes
Are you a recovering
alcoholic or addict? ...…….. Yes
O ther
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
Women O nly
Are you pregnant? ……...….. Yes
Is there a chance you
could be pregnant? ……….. Yes
Are you nursing
(breast-feeding)? .…..…….. Yes
How long?
Circle the following drugs that you are (the patient is) taking or have taken
Heart pills
Oral contraceptive
Antibiotics
Nitroglycerin
Steroids/Cortisone
Antihistamines
Digitals
Hormones
Cyclosporine A
Aspirin
Insulin
T ranquilizers
Blood thinners
Diabetic drugs
Sleeping pills
Blood pressure
T hyroid
Antidepressants
List all medications and doses that you are (the patient is) now taking:
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
No
No
No
No
No
No
No
No
No
No
No
No
When? _________________________
How many packs per day?
Name of person filling out form
No
No
No
No
No
No
No
Date
No
No
No