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Patient's name

Answer all questions by circling Yes (Y) or No (N) G.Insulin or Oral Anti-Diabetic drugs? . .Y N H. Digitalis, Inderal, Nitroglycerin or other heart drug?.……….Y N I. Are you taking or have you ever taken Bisphosphonates 3.Date of last physical exam ______________________________ _ (Fosamax or Actonel for osteoporosis, or 4. Are you now under a physician's care for chemotherapy for multiple myeloma, etc.)? . .Y N J. Please list any and all medications taken, including 5. Have you ever had any serious illnesses, prescription medications, over-the-counter mediations, operations or hospitalizations? If so, describe: . .Y N herbal or holistic remedies, vitamins or minerals: 9.ARE YOU ALLERGIC TO OR HAVE YOU HAD AN ADVERSE A.Rheumatic Fever or Rheumatic Heart Disease? . Y N A.Local Anesthesia (Novocain, etc.)? .Y N C.Cardiovascular Disease (Heart Attack., Heart Trouble, B.Penicillin or other antibiotics? . Y N Heart Murmur, Coronary Artery Disease, Angina, High Blood D. Lung Disease (Asthma, Emphysema, Chronic Cough, Bronchitis, Pneumonia, Tuberculosis, Shortness of Breath. Chest G.Other allergies or reactions? Please list . .Y N E. Seizures. Convulsions, Epilepsy, Fainting or 11. Is there any past history of Alcohol or Chemical Dependency or Emotional Disorder that may affect F. Bleeding Disorder, Anemia, Bleeding Tendency, Blood Transfusion? Do you bruise easily? . Y N 12. Have you had any serious problems associated with G.Liver Disease (Jaundice. Hepatitis)? . Y N 13. Have you or an immediate family member had any problem associated with intravenous anesthesia? . …Y N 14. Do you have any other disease, condition or problem not listed above that you think the doctor M.Glaucoma? . Y N N.Implants placed anywhere in your body 15. Do you wish to talk to the doctor privately (Heart Valve, Pacemaker, Hip, Knee)? . Y N O.Radiation (X-ray) treatment for Cancer? . Y N P.Clicking or popping of jaw joint, pain near ear, A. Are you Pregnant, or is there any chance difficulty opening mouth, grind or clench teeth? . Y N R. Any disease, drug or transplant operation C. If you are using Oral Contraceptives, it is important that you that has depressed your immune system? . Y N understand that antibiotics (and some other medications) may interfere with the effectiveness of oral contraceptives. Therefore, you will need to use mechanical forms of birth control for one B.Anticoagulants (Blood Thinners)? . Y N complete cycle of birth control pills. after the course of antibiotics C.Aspirin or drugs such as Motrin, Aleve, Ibuprofen? …………Y N or other medication is completed. Please consult with your D.High Blood Pressure medications? . Y N E.Steroids (Cortisone, etc.)? . Y N F.Tranquilizers . Y N I understand the importance of a truthful Health History to assist the doctor in providing the best care possible. I have had the opportunity to discuss my Heath History with my doctor. Signature of Person Completing Health History Medical Update: I have read my Health History dated ______________________ and confirm that it adequately states past and present conditions.

Source: http://olympicdental.net/wp-content/uploads/2013/02/Health-History-Form.pdf

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