Document

Health History

Name *

Email *

DOB *

Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions:

Dental Information

Do you have,or have you ever had any of the following dental conditions?

Do your gums bleed when you brush or floss?

Yes

Your teeth sensitive to cold, hot, sweets or pressure?

Yes

Does food or floss catch between your teeth?

Yes

Is your mouth dry?

Yes

Do you have an unpleasant taste or odour?

Yes

Do you smoke or use tobacco products?

Yes

How many times a day do you brush your teeth?

How many times a day do you floss?

Are you currently experiencing dental pain/discomfort?

Yes

Any problems associated with previous dental treatment?

Yes

Has the fear of discomfort kept you from Regular dental visits?

Yes

When was your last dental appointment?

How long has it been since last complete examination with a full series of x-rays?

Do you have earaches or neck pains?

Yes

Do you have any clicking, popping or discomfort in the jaw?

Yes

Do you grind your teeth?

Yes

Do you have any sores or ulcers in your mouth?

Yes

Do you wear dentures or partials?

Yes

Have you ever had a serious injury to your head or mouth?

Yes

How do you feel about your smile?

What prompted you to seek dental care at this time?

Medical Information

Do you have,or have you ever had any of the following medical conditions?

Anemia

Yes

Aids

Yes

Arthritis/Rheumatism

Yes

Artificial Heart Valves

Yes

Artificial Joints

Yes

Asthma

Yes

Back Problems

Yes

Blood Disease/Cancer

Yes

Blood Transfusion

Yes

Bleeding Abnormally with Extraction/Surgery

Yes

Cancer (recently diagnosed)

Yes

Cold sores/Fever Blisters

Yes

Cortisone Medication

Yes

Chemical Dependency

Yes

Chemotherapy

Yes

Chest Pain

Yes

Congenital Heart Problems

Yes

Diabetes

Yes

Do you wear contact lenses

Yes

Drug/Alcohol addiction

Yes

Eating Disorder

Yes

Epilepsy/Convulsions

Yes

Emphysema

Yes

Excessive Thirst

Yes

Frequent Cough

Yes

Frequent Diarrhea

Yes

Frequent Urination

Yes

Frequent headaches

Yes

Fainting or dizziness

Yes

Glaucoma

Yes

Genital Herpes

Yes

Gout

Yes

Hay Fever

Yes

Hemophilia

Yes

Heart Murmur

Yes

Heart Attack/Failure

Yes

Hive/Rash

Yes

Heart Problems

Yes

Hepatitis

Yes

Hepatitis Type

Herpes

Yes

Hypoglycemia

Yes

Hypertension/High Blood Pressure

Yes

HIV +

Yes

Irregular heartbeat

Yes

Jaw Joint Pain

Yes

Leukemia

Yes

Kidney Disease

Yes

Liver Disease

Yes

Lung Disease

Yes

Low Blood Pressure

Yes

Mitral Valve Prolapse

Yes

Pacemaker

Yes

Parathyroid Disease

Yes

Gastric ulcer/Gas Problems

Yes

Veneral Disease

Yes

Weight Loss Unexplained

Yes

Psychiatric Care

Yes

Radiation Treatment

Yes

Rheumatic Fever

Yes

Scarlet Fever

Yes

Sickle cell disease

Yes

Sinus Trouble

Yes

Shingles

Yes

Skin Rash

Yes

Spina Bifida

Yes

Special Diet

Yes

Stroke

Yes

Stomach/Intestinal Disease

Yes

Swelling Of Feet/Ankle

Yes

Swollen Neck Glands

Yes

Thyroid Problems

Yes

Tonsillitis

Yes

Traveller's Hepatitis (A)

Yes

HIV-AIDS-ARC

Yes

Tuberculosis

Yes

Tumor or Growth on head or neck

Yes

Yellow Jaundice

Yes

Women

Yes

Are you pregnant/trying to get pregnant ?

Yes

Due Date

Are you taking Birth control pills/oral/contraceptives ?

Yes

Are you lactating ?

Yes

Medications

Are You taking any Medication,Pills or Drugs ?

Yes

Please List all medications and doses

Allergies

Did you ever had an adverse reaction/allergies to any Medication or substances.
Please check if allergic to :

Aspirin

Yes

Acrylic

Yes

Barbiturates (sleeping pills)/Valium

Yes

Erythromycin

Yes

Metals

Yes

Nitrous Oxide

Yes

Tetracycline

Yes

Codeine

Yes

Iodine

Yes

Latex

Yes

Penicillin

Yes

Sulfa

Yes

Local Anasthetics (Novacaine)

Yes

Others

Other Information

Have you ever been told that you need “antibiotic prophylaxis”
prior to dental treatment?

Yes

Please tell us about antibiotics

Do you take,or have you taken,PhenFen or Redux?

Yes

Please tell us about your PhenFen usage

Adverse reactions to any medical or dental treatment?

Yes

Describe

Have you ever taken Fosamax, Boniva, Actonel or any other medications
containing bisphosphonates ?

Yes

Please tell us about your bisphosphonate usage

Have you recently used controlled substances ?

Yes

Please tell us which controlled substances and amount/frequency

Have you recently consumed alcohol?

Yes

Please tell us how much and how recently

Are you currently under the care of an M.D.?

Yes

For What

Have you recently been hospitalized or had a major operation?

Yes

Please tell us about hospitalization

Have you ever had a serious head or neck injury?

Yes

Please tell us about the head or neck injury

Do you use tobacco ?

Yes

Please tell us how often and what type of tobacco consumption

Is there anything else we should know about your medical history?

Yes

Describe

If we could offer you a simple, effective way of whitening your teeth,
would you be interested?

Yes

I certify that to the best of my knowledge, the questions on this form have been accurately answered. I understand the importance of a truthful health history and that my dentist and his/her staff will rely on this information for treating me. I understand that providing incorrect information can be dangerous to my (or patient’s) health. It is my responsibility to inform the dental office of any changes in medical status.

I will not hold Lehigh Valley Cosmetic Dentistry, my dentist, and his/her staff, responsible for any action they take or do not take because of errors or omissions that I may have made in the completion of this form

Signature of Patient / Legal Guardian

Date