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HEALTH HISTORY To our patients: Although oral surgeons primarily treat the area in and around your mouth, your mouth is part of your entire body. Health problems that you may have or medications you may be taking could have an important interrelationship with the care that you will be receiving. Thank you for answering the following questions. Your answers are for our records only and will be considered confidential. Are you currently taking any medications (prescribed or unprescribed): Do you have any allergies to medications? yes no Do you have a latex or rubber allergy? Do you have an allergy to egg or soy products? Do you take any blood thinner medication? Have you taken steroids (ex: Cortisone)? Have you ever taken bisphosphonates? (Ex: Fosamax, Zometa, Reclast, etc) Have you had any illness, operation, or been hospitalized in the past five years? Do you have any immune system disorders or recurrent infections? Do you smoke or chew tobacco? Do you drink alcoholic beverages? Do you premedicate with antibiotics prior to dental work? Do you use recreational drugs? FOR WOMEN ONLY: Are you pregnant? Please list medications: Please list allergies: Please list: Please list: Please list: Please list: Please list: Please list: How much & how long? If yes, how much? If yes, why? Which Trimester? PLEASE CHECK ANY CONDITIONS YOU MAY HAVE OR HAVE BEEN TREATED FOR IN THE PAST Heart Disease Bleeding Problems Liver Disease Heart Murmur/MVP Artificial Joints Sinus Disease Angina Arthritis Seizure Disorder Pacemaker/Defibrillator TMJ Nerve Disorder Rheumatic Fever Anemia Mental Illness High Blood Pressure HIV, AIDS Thyroid Disease Stroke GERD Migraines Lung Disease/COPD Stomach Ulcer Glaucoma Shortness of Breath Chemotherapy Diabetes Asthma (last attack ) Radiation Therapy Kidney Disease Hepatitis (type ) Cancer Tuberculosis Fainting Anorexia/Bulemia Eye Problems Have you or a family member ever had any complications with anesthesia?______________________________ Do you have any other condition, problem, or treatment we should be aware of?__________________________ I hereby grant Belmont Oral, Facial, & Implant Surgery permission to examine and/or administer such anesthetics and to perform such operations as may be deemed necessary or advisable in the diagnosis and treatment of this patient and that all the above information is correct to the best of my knowledge. ___________________________________________________________________________________________ Signature of Patient (or parent/legal guardian if under age 18) Date For office use only: ________________ ________________ ________________ Initialed/Dated Initialed/Dated Initialed/Dated ________________ Initialed/Dated
