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Sacramento Natural Dentistry

Health History


  First name

  Mid Initial

  Last name
This is a health history update. Please indicate anything regarding your health (Medical and Dental) that has changed since your last visit to our office. Thank you.









Medical/Dental History

Do you presently have or have had pain or discomfort in the mouth, face or jaws? Yes No
Do your gums bleed at any time? Yes No
Do you have aching or sensitive teeth? Yes No
Have you had an injury to your face or jaw? Yes No
Have you had serious trouble associated with any previous dental treatment? Yes No
Do you feel nervous or uneasy about having dental treatment? Yes No
Have you been a patient in a hospital during the past two years? Yes No
If Yes, Reason:
Have you been under the care of a medical doctor during the past two years? Yes No
If Yes, Reason:
Do you use tobacco products? Yes No
Do you drink alcoholic beverages? Yes No
How many per week:
Do you use recreational or street drugs? Yes No
Are you currently taking, or have you taken within the past two years, any prescription or non-prescription drugs? Yes No
If Yes, Please List:
DRUG DOSE/FREQUENCY REASON FOR TAKING
Do you have any allergies (i.e. itching, rash, swelling on hands, eyes, or are you made sick by metals, jewelry, latex rubber, aspirin, penicillin, codeine, or any drugs, foods, medication? Yes No
If Yes, Please List:
Have you ever had excessive bleeding requiring special treatment? Yes No
When you walk upstairs or take a walk, do you ever have to stop because of chest pain? Yes No
Do your ankles swell during the day? Yes No
Do you use more than two pillows to sleep? Yes No
Have you lost or gained more than 10 pounds in the last year? Yes No
Do you wake up short of breath? Yes No
Are you on a special diet? Yes No
Women: Are you pregnant now? Yes No
Women: Are you currently using a prescription-type contraceptive? Yes No
Do you snore, clench, or grind your teeth? Yes No
Does your jaw click when you open your mouth? Yes No
Have you previously had orthodontic treatment? Yes No
Do you wear a retainer? Yes No
Do you medicate before dental treatment? Yes No
Do you have any disease, condition, or problem not listed? Yes No
If Yes, Please Describe:

Please Indicate Any of The Following You Are Now Experiencing

Forehead headaches
Temporal headaches
Tension headaches
Migraine-type headaches
Sinus headaches
Back of head headaches
Scalp tender to touch
Lack of mobility
Stiffness
Neck pain
Tired/sore neck muscles
Shoulder pain
Back pain
Arm/finger pain or numbness
Jaw pain
Jaw joint pain
Clicking/popping in jaw joint(s)
Grinding sound in jaw joint(s)
Pain in cheek muscles
Uncontrollable jaw movements
Jaw locks open/shut
Deviation of jaw to one side
Ear pain without infection
Decreased hearing
Clogged/stuffy feeling in ear(s)
Itchy feeling in ear(s)
Ringing/buzzing in ear(s)
Dizziness
Balance problems
Pain in/around eyes
Bloodshot eyes
Sensitivity to light
Tearing of eyes
Blurred vision
Pressure behind eyes
Dark circles under eyes
Abnormal opening
Limited opening
Bad bite
Missing teeth
Clenching/grinding teeth
Mouth discomfort
Inability to find bite
Burning tongue
Sour or foul taste in mouth
Difficulty swallowing
Feeling of foreign object in throat
Sore throat without infection
Voice changes
Laryngitis
Frequent coughing or clearing
Sinus pain
Sinus problems
Post-nasal drainage
Allergies
Snoring
Sleep apnea
Have been told I snore
Have been told I stop breathing
Have awoken gasping for air

What Are The Chief Complaints For Which You Are Seeking Care.

Please Order Complaints By Number (1=Most Important, 10=Least)
Throat Pain Back Pain Pain Behind Eyes
Visual Disturbances Jaw Clicking Dizziness
Pain When Chewing Sinus Congestion Jaw Joint Noise
Ear Pain Ringing In Ears Muscle Twitching
Jaw Locking Facial Pain Shoulder Pain
Ear Congestion Jaw Pain Headaches
Limited Mouth Opening Neck Pain Fatigue
Inability To Open Mouth

Have You Taken Fosamax, Boniva, Or Any Other Bisphosphonate Drug In The Past? Yes No

Please List Other Health Providers You Are Currently Seeing

PRACTITIONER SPECIALTY TREATMENT RECEIVED APRX DATE

The Epworth Sleepiness Scale

The Epworth Sleepiness Scale (ESS) was developed and validated by Dr. Murray Johns of Melbourne, Australia. It is a simple, self-administered questionnaire that is widely used by sleep professionals in quantifying the level of daytime sleepiness.
How likely are you to doze off or fall asleep in the following situations, in contrast to feeling ‘just tired’? This refers to your usual way of life at present and in the recent past. Even if you have not done some of these things recently, try to work out how they would have affected you.
Use the following scale to choose the most appropriate number for each situation:
0 = Would Never Doze 1 = Slight Chance Of Dozing
2 = Moderate Chance Of Dozing 3 = High Chance Of Dozing
Situation:
Siting and reading
Watching television
Sitting inactive in a public place (e.g. theatre, meeting)
As a car passenger for an hour without a break
Lying down to rest in the afternoon when circumstances permit
Sitting and talking to someone
Sitting quietly after lunch without alcohol
In a car, while stopping for a few minutes in traffic

TOTAL SCORE:

Please Indicate Any Medications/Substances Which Have Caused An Allergic Reaction

Antibiotics
Aspirin
Barbiturates
Codeine
Iodine
Latex
Local Anesthetic
Metals
Penicillin
Plastics
Sedatives
Sleeping Pills
Sulfa Drugs

Please List All Medications Currently Being Taken

Antibiotics
Anticoagulants
Barbiturates
Blood Thinners
Codeine
Cortisone
Diet Pills
Heart Medication
Insulin
Muscle Relaxants
Nerve Pills
Pain Medication
Sleeping Pills
Sulfa Drugs
Tranquilizers

Please Update The Following Medical/Dental History

DETAILS
AIDS or HIV antibody:
Artificial Joint:
Artificial Heart Valve:
Adenoids Removed:
Tonsils Removed:
Anemia:
Angina (Chest Pain):
Arteriosclerosis:
Asthma:
Autoimmune Disorder:
Bleeding Easily:
High Blood Pressure:
Low Blood Pressure:
Bruising Easily:
Cancer:
Chemotherapy:
Chronic Fatigue:
Cold Hands/Feet:
Cold Sores/Fever Blisters:
Current Pregnancy:
Depression:
Diabetes:
Difficulty Focusing:
Dizziness:
Emphysema:
Epilepsy/Seizures:
Excessive Thirst:
Fluid Retention:
Frequent Cough:
Frequent Illness:
Frequent Stress:
General Anesthesia:
Glaucoma:
Gout:
Hay Fever:
Hearing Impairment:
Heart Murmur:
Heart Disorder:
Heart Pacemaker:
Heart Palpitations:
Heart Valve Repl.:
Hemophilia:
Hepatitis:
Hypoglycemia:
Immune Disorder:
Injury To Face:
Injury To Neck:
Injury To Mouth:
Injury To Teeth:
Insomnia:
Intestinal Disorder:
Irritable Bowel:
Jaw Joint Surgery:
Kidney Problems:
Liver Disease:
Meniere’s Disease:
Menstrual Cramps:
Multiple Sclerosis:
Muscle Aches:
Muscle Tremors:
Muscle Cramps:
Muscular Dystrophy:
Need Pillow At Night:
Nervous Irritability:
Nervousness:
Neuralgia:
Osteoporosis:
Parkinson’s Disease:
Poor Circulation:
Prior Orthodontics:
Psychiatric Care:
Radiation Treatment:
Rheumatic Fever:
Rheumatoid Arthritis:
Scarlet Fever:
Shortness Of Breath:
Sickle Cell Disease:
Sinus Problems:
Skin Disorders:
Slow Healing Sores:
Speech Difficulty:
Stroke:
Stomach problems/ Ulcers:
Swollen Joints:
Frequent Colds:
Freq Sore Throat:
Freq Ear Infection:
Thyroid Disease:
Tuberculosis:
Tubes In Ears:
Tumors:
Urinary Disorders:
Wisdom Teeth Extraction:
Fosamax Use:

Bisphosphonate Drugs

***If you take any of the following, let our staff know immediately

Please read the list below and mark the appropriate choice.
Actonel (risendronate)
Actonel Plus Ca (risendronate + Ca)
Aredia (pamidronate)
Boniva (ibandronate)
Didronel (etidronate)
Fosamax (alendronate)
Fosamax Plus D (Alendronate + Vit. D)
Reclast (zoledronic)
Skelid (tiludronte)
Zometa (zoledronic)
I do not take any of the drugs listed above.

'Jaw osteonecrosis seems to be associated with trauma. Most cases occur after extractions and are located near the mylohyoid ridge. Of those not associated with extractions, they are commonly associated with dentures or exostoses. Chronic periodontitis also increases the risk of osteonecrosis development. Osteonecrosis will appear as exposed yellow-white bone. Sinus tracts and painful ulcers may also be present. (1)'

Adult/Child Health History

Is the patient an Adult or a Child? Adult Child

Adult Health History

Child Health History

Birthday:


Was your child breast fed? Yes No
If your child was breast fed – for how long?
Was your child Full Term Premature
If Premature – at how many weeks was your child delivered?

MEDICATIONS

(including prescription and over-the-counter)
1. 2.
3. 4.
5. 6.
7. 8.
Do you have any allergies to any medications? Yes No
Does your child have any allergies to any medications? Yes No
If yes – please list:

PAST SURGICAL HISTORY

1. 2.
3. 4.
5. 6.
7. 8.
Have you ever had your tonsils and/or adenoids surgically removed? Yes No
Has your child ever had your tonsils and/or adenoids surgically removed? Yes No

SOCIAL HISTORY

Caffeine:
# of cups of coffee per day # of cups of tea per day
# cans or glasses of soda per day # of servings of chocolate per week
# of energy drinks per day
Alcohol: None Yes
# of drinks per day # of drinks per week
# of drinks per month
Tobacco: None Yes
# of packs per day # of years
Recreational Drugs (such as marijuana or cocaine): None Yes
If yes, which ones?
Marital Status : Single Married Divorced Widowed
Children: Yes No How many?
Pets: Yes No How many?
What type of pet?
Do you have any children or pets that sleep in your bedroom? Yes No

ALLERGY HISTORY

None Known Yes, to:
Pets: Yes No How many?
What type of pet?
Do any pets sleep in your child’s bedroom? Yes No
Which pets?

FAMILY HISTORY

Do you have a family history of any of the following medical illnesses?

High blood pressure/hypertension
Diabetes
Chronic insomnia
Heart disease
Overweight/obesity
Restless legs syndrome
Stroke
Snoring
Multiple sclerosis
Congestive heart failure
Sleep apnea
Sleep walking
Depression
Anxiety

REVIEW OF SYMPTOMS

Loss of Appetite / Sweats
Loss of Appetite
Fever
Fatigue
Weight Gain
Weight Loss
Cough
Asthma
Wheezing
Poor Exercise Tolerance
GERD/Heartburn/Indigestion
Heartburn/Indigestion
Black or Bloody Stools / Diarrhea
Nausea/Vomiting
Jaundice
Abdominal Pain
Bed Wetting
Frequent Urination
Difficulty Urinating
Blood in Urine
Erectile dysfunction
Sneezing
Runny Nose
Itchy Eyes or Nose: Hives
Itchy Eyes or Nose
Hives
Nasal allergies/Hay fever/Nasal Congestion
Stiff/Sore Joints
Muscle Pain
Red or Swollen Joints
Temporomandibular Joint (TMJ) pain/jaw discomfort
Blurry Vision
Double Vision
Vision Loss
Hearing Loss
Sore Throat
Sinus Congestion
Hoarseness
Tubes in Ears
Palpitations
Chest Pain
Daytime Shortness of Breath
Nighttime Shortness of Breath
Ankle Swelling
Hypertension/High Blood Pressure
Weakness
Seizures
Involuntary Tongue Biting
Passing Out
Dizziness
Headaches
Numbness
Restless Leg Syndrome
Unusual Moles
Rash
Dryness
Excessive Stress
Memory Loss
Difficulty with Focus
Trouble Concentrating
Hallucinations
Nervousness or Anxiety
Depressed Mood
Heat Intolerance
Excessive Thirst
Constipation
Cold Intolerance
Cold Hands/Feet
Decreased Libido
* I Certify That The Above History Is True And Correct To The Best Of My Knowledge.
*Signature:
Date:
(Your digital signature (full name) is as legally binding as a physical signature.)