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West Portal Family Dentistry
Print blank form to fill by hand

Patient Name:*

Last name

Mid name

First name

Patient Phone #:

()- -

Emergency Contact Details-

Contact Name:

Contact Phone #:

()- -

Physician Details-

Physician Name:

Hospital or HMO #

Physician Phone #:

()- -

Health History

Please Answer All Questions-

Has there been any changes in your health in the past two years?

Yes No

Date of last medical examination:

3.	Are you under physician’s care now?	Yes No
4.	Have you ever been hospitalized or had a serious illness?	Yes No
5.	Are you taking any meditations or drugs including over the counter medicines or oral contraceptives?	Yes No

If Yes, Please List:

6.	Have you ever taken diet drugs Fen-Phen or Redux?	Yes No
7.	Do you take anticoagulant or blood thinner medicine?	Yes No
8.	Are you using any recreational drugs or tobacco?	Yes No

(For women)-

Are you pregnant?

Yes No

If Yes, Months:

Any complications with past pregnancies?

Are you nursing at present?

Yes No

Do you have now or have you ever had any of the following?

10.	Heart disease, pacemaker, irregular heartbeat, or endocarditis.	Yes No
11.	Shortness of breath with limited activity or when lying down.	Yes No
12.	Chest pains or angina pectoris or heart attack.	Yes No
13.	Rheumatic fever or rheumatic heart disease.	Yes No
14.	Heart murmur, mitral valve prolapse, or heart defect from birth.	Yes No
15.	Strokes, severe headaches, numbness, or tingling sensations.	Yes No
16.	High blood pressure or low blood pressure.	Yes No
17.	Fainting spells, convulsions, or epilepsy.	Yes No
18.	Nervous breakdown, emotional problems, anxiety, or depressive disorder.	Yes No
19.	Lung disease (T.B., asthma, emphysema, bronchitis, or other breathing problems).	Yes No
20.	Liver disease (hepatitis, jaundice, cirrhosis or problem with drinking.	Yes No
21.	Kidney disease, dialysis, or transplant.	Yes No
22.	Prolonged bleeding following injuries, surgeries, or transfusion?	Yes No
23.	Diabetes?	Yes No
24.	Any diet or activity limitation?	Yes No
25.	Venereal disease (syphilis, gonorrhea, herpes, warts, other)?	Yes No

If Other, Explain:

26.	Blood disorder (anemia, leukemia, or other)	Yes No
27.	Thyroid diseases?	Yes No
28.	Thrombophlebitis?	Yes No
29.	Cancer or cancer treatment (radiation, surgery, or chemotherapy)?	Yes No
30.	AIDS or immunosuppressive disorders?	Yes No
31.	Ulcers, stomach or intestinal disease?	Yes No
32.	An unusual reaction to any dental treatment?	Yes No

Explain:

33.	Arthritis, rheumatism, painful swollen joints, osteoporosis.	Yes No
34.	Artificial implants – hips or others.	Yes No
35.	Any visual disorder ( glaucoma or other),	Yes No
36.	Any hearing impairment.	Yes No

Have you become sick from, shown any allergy to or have been told not to take the following meditations:

37.	Novacaine, xylocaine, or other anesthetics.	Yes No
38.	Penicillin, or other antibiotics.	Yes No
39.	Aspirin, codeine, Demerol, Valium, barbiturates, or other pain medications.	Yes No
40.	Other medications or allergies, hay fever, hives, skin rash, allergy to latex.	Yes No
41.	Is there anything of importance in your medical history that has not been asked?	Yes No

Explain:

ARE YOU OR HAVE YOU EVER TAKEN BISPHOSPHONATE DRUGS?

Yes No

*Signature:		Date:
(Your digital signature (full name) is as legally binding as a physical signature.)