Patient’s Information Health History Form

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…………………………………………………………………………………………………………………………………………………………………………. □ □
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Persistent cough greater than 3 weeks duration…………………………………………………………………………………………………………………………….. □ □
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Cough that produces blood…………………………………………………………………………………………………………………………………………………………….. □ □
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Been exposed to anyone with tuberculosis……………………………………………………………………………………………………………………………………..□ □
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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
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Yes No DK
Do you have earaches or neck pains?............................................ □
Do you have any clicking, popping or discomfort
in the jaw?.................................................................................................. □
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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
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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?
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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?
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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?
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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__________________________________________ □
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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?....................................................................
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Women Only Are you:
Pregnant?......................................................................................................... □
If so, number of weeks:_______________________________
Nursing?......................................................................................................….. □
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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 _______________