Health History Questionnaire OLD
First Name: Last Name: Contact Number:
E-mail: Address:
Are you taking any medication(s) including non-prescription medicine? Yes No
Have you ever taken prescription medications for weight loss (diet pills)? If so, did you take any of the following:
Do you have any of the following?
High blood pressure Heart attack Rheurnatic Fever Heart disease Pacemaker Heart murmur Mitral Valve Prolapse Joint replacement or implant Respiratory problems Diabetes Epilepsy/Convulsions Hemophilia, abnormal bleeding AIDS or HIV Leukemia Cancer Hepatitis/Jaundice Tuberculosis (TB) Hay fever/Allergies Thyroid problems Other None of the above
Are you allergic to any of the following?
Local anesthetics (e.g. Novocain) Penicillin or another other antibiotics Aspirin Codeine Sulfa drugs Any metals (e.g. nickel, mercury, etc.) Latex rubber Other None of the above
Do you smoke or use tobacco? If yes, please use comments to specify how many packs per day.
Yes No
Women only! Are you pregnant or think you might be pregnant?
No Yes, I'm pregnant
DENTAL HISTORY: What is the main purpose of your visit today?
Checkup Tooth ache Teeth or gums hurting or bothering me Other
When was the last time you were seen by a dentist for a complete dental examination or teeth cleaning?
Date:
Gums bleed while brushing or flossing Food tend to become caught in between teeth Clench or grind teeth Have tired jaws, especially in the morning Feel pain in some teeth Any other dental problems None of the above
Is there anything else about having dental treatment that you would like us to know?
I hereby acknowledge that my answers are accurate and to the best of my knowledge. I authorize Perfect Smile Dental Care to take X-rays, photographs deemed appropriate, and to make a thorough diagnosis of my dental needs.
I Agree I Disagree
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