Health History Form Please complete this entire front page to the best of your ability. PLEASE PRINT Today’s Date:_________________ Patient’s Information Last Name_______________________________ First Name___________________________ Middle Initial____ Address____________________________________Apt#_________City____________State_____Zip________ Home Phone____________________ Work Phone_____________________ Cell_________________________ Email Address_____________________________________ Date of Birth_____________________ Sex: M F Social Security No________________________ Driver’s License No_____________________ State__________ Employer_____________________________________Address_______________________________________ City_____________________________State_________________________Zip__________________________ Do you have any of the following diseases or problems? (Check DK if you don’t know the answer to the question) Yes No DK Active tuberculosis…………………………………………………………………………………………………………………………………………………………………………. □ □ □ Persistent cough greater than 3 weeks duration…………………………………………………………………………………………………………………………….. □ □ □ Cough that produces blood…………………………………………………………………………………………………………………………………………………………….. □ □ □ Been exposed to anyone with tuberculosis……………………………………………………………………………………………………………………………………..□ □ □ If you answer yes to any of the 4 items above, please stop and return this form to the receptionist. Responsible Person’s Information for Insurance Purposes (unless same as above) Last Name_______________________________ First Name____________________________ Middle Initial___ Address___________________________________ Apt#_____ City_______________ State____ Zip_________ Home Phone____________________ Work Phone____________________ Cell__________________________ Email Address_____________________________________ Social Security No___________________________ Driver’s License No__________________ Relationship to Patient______________________________________ Employer________________________________________ Employer’s Phone____________________________ Company Insurance Plan__________________________________ Plan/Group No________________________ Policyholder’s Full Name_____________________________ DOB_____/_____/_____ SS No________________ Dental Information For the following questions, please mark (X) your responses to the following questions. Answer DK if you don’t know the answer. Yes No DK Do your gums bleed when you brush or floss?................................ □ Are your teeth sensitive to cold, hot, sweets, or pressure?........ □ Does food/floss catch between your teeth?...................................... □ Is your mouth dry?....................................................................................... □ Have you had any periodontal (gum) treatments?........................ □ Have you ever had orthodontic (braces) treatment?.................... □ Have you had any problems associated with previous dental treatment?........................................................................................................ □ Is your home water supply fluoridated?............................................. □ Do you drink bottled or filtered water?.............................................. .□ If yes, how often? Circle one: Daily/Weekly/Occasionally □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ Yes No DK Do you have earaches or neck pains?............................................ □ Do you have any clicking, popping or discomfort in the jaw?.................................................................................................. □ □ □ □ □ Do you brux or grind your teeth?.................................................... □ □ □ Do you have sores or ulcers in your mouth?.............................. □ □ □ Do you wear dentures or partials?................................................. □ □ □ Do you participate in active recreational activities?.............. □ □ □ Have you had a serious injury to your head or mouth?... .... □ □ □ Are you currently experiencing dental pain or discomfort...□ □ □ What is the reason for your dental visit today? How did you hear about our office?____________________________________________________________________________________ Who is your General Dentist?____________________________________________________ Phone:______________________________ Emergency Contact: _________________________________________________________ Phone:____________________________________ (PLEASE SEE REVERSE SIDE TO COMPLETE MEDICAL HISTORY) MEDICAL HISTORY: Please mark your responses to ALL items below. Check DK if you don’t know the answer to the question. Yes No DK Yes No DK Are you under a physician’s care now?............................................... □ □ □ Do you use controlled substances?....................................................... □ □ □ If so, why? Do you use tobacco (smoking, snuff, chew, bidis)?........................ □ □ □ Physician Name: Address/City/State/Zip: Phone: ( include area code ) Are you in good health?............................................................................ Has there been any change in your general health in the past year?............................................................ If yes, what condition is being treated? □ □ □ □ □ □ Date of last physical exam: If so, how interested are you in stopping? Circle one: Very/ Somewhat/ Not Interested Do you drink alcoholic beverages?........................................................ □ If yes, how much did you drink in the last 24 hours?_________________________ If yes, how much do you typically drink in a week?___________________________ Joint Replacement Have you had an orthopedic total joint (hip, knee, elbow, finger) replacement?.................................................................... □ If so, Date:________________________ If so, have you had any complications? □ □ □ □ Allergies: Are you allergic or have you had a reaction to: To all yes responses, specify type of reaction. Have you had a serious illness, operation or been Hospitalized in the past 5 years?.......................................................... □ If yes, what illness or problem? □ □ Local anesthetics – PLEASE SPECIFY____________________________ □ Aspirin______________________________________________________________ □ Penicillin____________________________________________________________ □ Other Antibiotics – PLEASE SPECIFY_____________________________ □ Barbiturates, sedatives, or sleeping pills_________________________ □ Sulfa drugs__________________________________________________________ □ Codeine or other Narcotics – PLEASE SPECIFY__________________ □ Are you taking or have you recently taken any prescription or over the counter medicine(s)?........................................................ □ □ □ If so, please list all, including vitamins, natural or herbal preparations and/or diet supplements: Metals_______________________________________________________________ □ Latex (rubber)______________________________________________________ □ Iodine_______________________________________________________________ □ Hay fever/seasonal________________________________________________ □ Animals – PLEASE SPECIFY_______________________________________ □ Food – PLEASE SPECIFY__________________________________________ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ Seafood – PLEASE SPECIFY_______________________________________ □ Other-SPECIFY__________________________________________________________________ Are you taking, or have you taken any diet drugs such as Pondimin (fenfluramine), Redux (dexphenfluramine) or phen-fen (fenfluramine-phentermine combination)?................ □ □ □ Since 2001, were you treated or are you presently scheduled to begin treatment with the intravenous bisphosphonates (Aredia or Zometa) for bone pain, hypercalcemia or skeletal complications resulting from Paget’s disease, multiple myeloma, or metastatic cancer?................................................................................ □ □ □ If so, Date treatment began:___________________________________________________ Do you wear contact lenses?.................................................................... □ □ □ Women Only Are you: Pregnant?......................................................................................................... □ If so, number of weeks:_______________________________ Nursing?......................................................................................................….. □ □ □ □ □ Taking birth control pills?...................................................................….. □ □ □ Taking hormonal replacement?.............................................................. □ □ □ Please check (√) if your response is YES to having any of the following diseases or problems. If NONE of these apply, mark NONE_____ Heart murmur ____ Mitral valve prolapse____ Artificial heart valves____ Rheumatic fever____ Cardiovascular disease____ Angina____ Arteriosclerosis____ Congestive heart failure____ Coronary artery disease____ Damaged heart valves____ Heart attack____ Low blood pressure____ High blood pressure____ Congenital heart defects____ Pacemaker____ Rheumatic heart disease____ Abnormal bleeding____ Anemia____ Blood transfusion___date:____ Hemophilia____ AIDS or HIV infection____ Arthritis____ Autoimmune disease____ Rheumatoid arthritis____ Systemic lupus eythematosus__ Asthma____ Bronchitis____ Emphysema____ Sinus trouble____ Tuberculosis____ Cancer/chemotherapy/ Radiation treatment____ Chest pain upon exertion____ Chronic pain____ Diabetes Type I____ or II____ Eating disorder____ Malnutrition____ Gastrointestinal disease____ G.E. Reflux/heartburn____ Ulcers____ Thyroid problems____ Stroke____ Glaucoma____ Hepatitis-specify type________ Jaundice or liver disease____ Epilepsy____ Fainting spells or seizures____ Neurological disorders____ If yes, specify:____________ Sleep disorder____ Mental health disorders____ Specify:___________________ Recurrent infections____ Type of infection___________ Kidney problems____ Night sweats____ Osteoporosis____ Persistent swollen glands in neck____ Severe headaches/migraines___ Severe or rapid weight loss___ Sexually transmitted disease___ Excessive urination____ Note: Both Doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment. I certify that I have read and understand the above and that the information given on this form is accurate. I understand the importance of a truthful health history and that Dr. Alongi and his staff will rely on this information for treating me. I acknowledge that my questions, if any, about inquiries set forth above have been answered to my satisfaction. I will not hold Dr. Alongi or any other 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. Signature of Patient/Legal Guardian_______________________________ Date _______________