PATIENT HEALTH HISTORY FORM

FORM #2 --- Please compete these forms, and bring them with you for your first appointment. It will save you several minutes! Thank You, Dr. Waldrop and staff. ( Thank you for taking the time to make sure we treat you with care. We know this is a rather long form, however, it is very important that you complete all that applies to you for your protection.) Patient's Full Name: ___________________________Date:_______________________ Date of Birth: _____________________________________ Dental Health [ ] Do your gums bleed when you brush? [ ] Are your teeth sensitive to cold, hot, sweets, or pressure? [ ] Have you had previous periodontal (gum) treatments? [ ] Have you had previous orthodontic treatment? [ ] Do you have headaches, earaches, or neck-pain? [ ] Do your wear removable dental appliances? If you had a serious or difficult dental problem in the past, please explain below: Date of your last dental exam: ____________________ What was done at that time? __________________________________________ How do you feel about your teeth? _____________________________________ Current or main complaint:_______________________________________ Medical Health History: Circle One! Yes ------- No ---------- Don't Know ---- Are you in good health? Yes ------- No ---------- Don't Know---- Has there been any change in your health in the past year? Do you have any of the following disease problems? Yes ------- No ---------- Don't Know ---- Active Tuberculosis? Yes ------- No ---------- Don't Know ---- Persistent cough longer than 3 week duration? Yes ------- No ---------- Don't Know ---- Cough that produces blood? If your answer to one of the last three questions was "yes" call (309) 691-6402 Yes ------- No ---------- Don't Know ---- Are you under the care of a physician? If so, what condition is being treated? _______________________________________________ Date of last Physical examination?__________________ Physician's name:________________________________ Physician's phone:_________________ Yes ------- No ---------- Don't Know ---- Have you had a serious illness, operation or been hospitalized? Yes ------- No ---------- Don't Know ---- Are you taking any medications --- including non prescription? ____________________________________________________________ If more than 2, please bring a list of your medications. Yes ------- No ---------- Don't Know ---- Are you taking or have taken any diet drugs such as Pondimin, Redux or Phen-fen? Yes ------- No ---------- Don't Know ---- Are you alcohol or drug dependent? Yes ------- No ---------- Don't Know ---- Do you use recreational drugs? Yes ------- No ---------- Don't Know ---- Do you use tobacco? Yes ------- No ---------- Don't Know ---- Do you wear contact lenses? Allergies: Yes ------- No ---------- Don't Know ---- Local Anesthetics Yes ------- No ---------- Don't Know ---- Aspirin Yes ------- No ---------- Don't Know ---- Penicillin or other Antibiotics Yes ------- No ---------- Don't Know ---- Barbiturates, sedatives Yes ------- No ---------- Don't Know ---- Sulfa drugs Yes ------- No ---------- Don't Know ---- Narcotics Yes ------- No ---------- Don't Know ---- Latex Yes ------- No ---------- Don't Know ---- Animals Yes ------- No ---------- Don't Know ---- Iodine Yes ------- No ---------- Don't Know ---- Foods Yes ------- No ---------- Don't Know ---- Hay Fever Yes ------- No ---------- Don't Know ---- Other? ________________________________ If your answer to one of the last 6 questions was yes, please explain reaction: Yes ------- No ---------- Don't Know ---- Are you pregnant? Yes ------- No ---------- Don't Know ---- Nursing? Yes ------- No ---------- Don't Know ---- Had a total joint replacement? When?__________ Yes ------- No ---------- Don't Know ---- Physician/Dentist recommended antibiotics before treatment? The July 1997 report of the American Academy of Orthopedic Surgeons recommended that antibiotic prophylaxis before dental treatment is no longer indicated for most patients with prosthetic joints. You should discuss this with your physician before any treatment in this office. If you wish to be covered by antibiotics, we will need a written statement by your physician for coverage, and his recommended choice of drug and dosage. Yes ------- No ---------- Don't Know ---- Abnormal bleeding Yes ------- No ---------- Don't Know ---- AIDS or HIV Yes ------- No ---------- Don't Know ---- Arthritis Yes ------- No ---------- Don't Know ---- Rheumatoid arthritis Yes ------- No ---------- Don't Know ---- Hepatitis Yes ------- No ---------- Don't Know ---- Cardiovascular problems Yes ------- No ---------- Don't Know ---- Chronic diarrhea Yes ------- No ---------- Don't Know ---- Mental health disorder Yes ------- No ---------- Don't Know ---- Respiratory problems Yes ------- No ---------- Don't Know ---- Stroke Yes ------- No ---------- Don't Know ---- Thyroid problems Yes ------- No ---------- Don't Know ---- Ulcers Yes ------- No ---------- Don't Know ---- Herpes Yes ------- No ---------- Don't Know ---- Immunosuppression problems Yes ------- No ---------- Don't Know ---- Anemia Yes ------- No ---------- Don't Know ---- Epilepsy Yes ------- No ---------- Don't Know ---- Glaucoma Yes ------- No ---------- Don't Know ---- Hemophilia Yes ------- No ---------- Don't Know ---- Chest pain Yes ------- No ---------- Don't Know ---- Kidney problems Yes ------- No ---------- Don't Know ---- Osteoporosis Yes ------- No ---------- Don't Know ---- Sexually Transmitted Diseases (STD) Yes ------- No ---------- Don't Know ---- Lupus erythematosis Yes ------- No ---------- Don't Know ---- Tuberculosis Yes ------- No ---------- Don't Know ---- Night Sweats Yes ------- No ---------- Don't Know ---- Heart Murmur Any other diseases or conditions you think we should know about? I certify that I have read and understand the above. I acknowledge that my questions, if any, have been answered to my satisfaction. I will not hold my dentist or any member of his 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. I verity that the above information is correct to the best of my ability, and I agree to pay 18% interest per year on any of my charges not paid within 30 days from the date of treatment. Signature of patient or legal guardian if patient is 1-18 years of age: Signature: ________________________ Date:______________ © 2002 American Dental Association All Rights Reserved Reproduction and use of this form by dentists and their staff is permitted. Any other use, duplication or distribution of this form by any other party requires the prior written approval of the American Dental Association.