HEALTH HISTORY Name_______________________________
I. Check Appropriate Answers: (Leave blank if you do not understand the question)
Yes No 1. Is your general health good?_______________________________________________________
Yes No 2. Has there been a change in your health within the last year?___________________________
Yes No 3. Have you been hospitalized or had a serious illness in the last three years?_______________________
Please explain________________________________________________
Yes No 4. Are you being treated by a Physician now?___________________________________________________
Please explain_____________________________________________________________
Date of last general exam ____/_____/_______Date of last Dental exam____/____/____
5. If yes to 4 above, name of Medical Doctor___________________Phone Number (_____)__________
Yes No 6. Have you had problems with prior dental treatment?
Please explain___________________________________________________________________
Yes No 7. Are you in pain now ? Explain_______________________________________________________________________________
II. Have You Experienced:
YES NO 8. Chest pain (angina) ? YES NO 19. Dizziness?
YES NO 9. Swollen ankles YES NO 20. Ringing in the ears?
YES NO 10. Shortness of breath? YES NO 21. Headaches?
YES NO 11. Recent weight loss, fever, night sweat? YES NO 22. Fainting spells?
YES NO 12. Persistent cough, Coughing up blood? YES NO 23. Blurred vision?
YES NO 13. Bleeding problems, bruising easily? YES NO 24. Seizures?
YES NO 14. Sinus problems? YES NO 25. Excessive thirst?
YES NO 15. Difficulty swallowing ? YES NO 26. Frequent urination?
YES NO 16. Diarrhea, constipation, blood in stools ? YES NO 27. Dry mouth?
YES NO 17. Frequent vomiting, nausea? YES NO 28. Jaundice ?
YES NO 18. Difficulty urinating, blood in urine ? YES NO 29. Joint pain, stiffness?
III. Do you Have Or Have You Had:
YES NO 30. Heart disease? Explain____________________ YES NO 41. AIDS or ARC?
YES NO 31. Heart attack? Explain____________________ YES NO 42. HIV positive
YES NO 32. Heart murmur? YES NO 43. VD (syphilis or gonorrhea) ?
YES NO 33.High Blood pressure? YES NO 44. Herpes?
YES NO 34. Stroke, hardening of arteries? YES NO 45. Skin diseases?
YES NO 35. Rheumatic fever? YES NO 46. Eye disease?
YES NO 36. TB, emphysema, other lung diseases? YES NO 47. Anemia
YES NO 37. Hepatitis, other liver disease? YES NO 48. Arthritis, rheumatism?
YES NO 38. Stomach problems, ulcers? YES NO 49. Kidney, bladder disease?
YES NO 39.Allergies to: latex, food, medications?_________ YES NO 50.Thyroid, adrenal disease?
YES NO 40. Family history of diabetes, heart problems, tumors ? YES NO 51. Diabetes?
IV. Do You Have Or Have You Had: V. Are You Taking:
YES NO 52. Tumors, cancer? YES NO 62.Recreational drugs? (Addiction)
YES NO 53. Radiation treatments? YES NO 63. Tobacco in any form?
YES NO 54. Quemotherapy YES NO 64. Alcohol?
YES NO 55. Prosthetic heart valve? YES NO 65. Drug, medicines, (including Aspirin,Phen-Phen) ?
YES NO 56. Artificial joint? Please list______________________________
YES NO 57. Contact lenses? YES NO 66. Are you taking any Phen-fen, Bisphosphates (Fosamax,
YES NO 58. Blood transfusions? Actonel, Bonivia..)?
YES NO 59. Surgeries? VI. Women Only:
YES NO 60. Pacemakers? YES NO 67. Are you or could you be pregnant or nursing?
YES NO 61. Psichiatric Care? YES NO 68. Taking birth control pills ?
VII. All Patients:
YES NO 69. Do you have had any other diseases or medical problems NOT listed on this form?
Please explain__________________________________________________________________________
To the best of my knowledge, I have answered every question completely and accurately. I will inform Dr. Ingrid Mack of any change in
my health and or medication.
Date____/____/_____ Patient’s Signature_________________________Doctor_______________________