Microsoft word - health_history (office).doc
Balentine Plaza Dental Care, Teresa T. Mercado, DDS & Huang Kevin Cheng, DDS
Mr. Mrs. Miss
________________________________________ D.O.B ____________ Age _____SS# ___________________________
Home Address ________________________________________ City __________________ State _____ Zip: ______________________
) __________________________ (Work
) ________________________ (Cell
E-mail address: __________________________________________________________________________________________________
Referred By ________________________________________
Occupation _________________________________ Employer _____________________________ Phone: ________________________
Person to contact in case of emergency ________________________________________________ Phone: _________________________
Dental Insurance ________________________________________ Group or Plan #: ___________________________________________
Guarantor _______________________________________ Relationship to you _______________________________________________
Guarantor SS# ____________________
Spouse Name ___________________________ Spouse D.O.B ____________________ Employer: _______________________________
Date of last health care exam: ________________ What was this exam for? __________________________________________________
Have you been hospitalized in the last 5 years? (Please circle
If yes, reason: ___________________________________________________________________________________________________ Are you currently receiving care? No Yes
If yes, nature of care: __________________________________________________
Please list all the names and phone numbers of the physicians who are currently providing you care:
1. ____________________________________________________________________ 2. ____________________________________________________________________ 3. ____________________________________________________________________ 4. ____________________________________________________________________
Is there anything about your smile that you would like to improve?
If yes, reason: ___________________________________________________________________________________________________ For the following questions circle yes or no. Your answers are for our records only and will be confidential. Please note that during
your initial visit you will be asked some questions about your response. Our team may ask additional questions concerning your health.
Anemia or Blood Disorder?
Arthritis, Rheumatism or other inflammatory disease?
Emphysema or other Respiratory/Lung Illnesses
Abnormal Heart or Previous Bacterial Endocarditis
Heart Valve (artificial) or Heart Transplant
Heart Disease, Heart Attack, Heart Surgery
Are you taking any of these medications?
Pre-medication before dental treatment?
Yes Tagamet® (cimetidine) or Prilosec® (omeprazole)?
Yes Cardizem® (diltiazem) or Calan, Isoptin® (Verapamil)?
Yes Diflucan® (fluconazole) or Sporonox® (itraconazole)
Have you been treated with Bisphosphonate drugs (Fosamax®, Aredia®, Zometa®, Actonel®, Boniva®)? If so, when did
the treatment begin? When did the treatment end? Have you ever taken any prescription drugs such as fen-phen for weight loss?
Do you consume grapefruit juice, grapefruits or grapefruit extract?
Please list any medications, dietary or herbal supplements you are currently taking dosages & for what purpose:
If no, are you planning a pregnancy in the near future?
Abnormal Blood Pressure? (Please circle
Have you ever received a diagnosis of “high blood pressure”? What is your normal blood pressure?
Are you allergic or have you had a reaction to:
a. Local anesthetics ……………………………………………………….
b. Penicillin or other antibiotics ……………………………………………
c. Aspirin, Ibuprofen or Tylenol ….………………………………………
d. Codeine, Valium or other sedatives……………………………………
e. Latex or Metals f. Other (please specify)____________________________________________________
Tobacco, Alcohol, Drugs
Do you use tobacco? If yes, circle type: smoke chew How much per day? For how long?
Do you consume alcohol? If yes, approximately how many alcoholic beverages per week?
Do you use any mood altering drugs other than those previously listed?
Weight and Diet considerations
Sugar in your diet (circle one
): none slight moderate high DOCTOR’S USE ONLY
Comments on patient interview concerning medical history:
Significant findings from questionnaire or oral interview:
Dental management considerations:
_______________________________________________________________________________________________________________ I understand the above information is necessary to provide me with dental care in a safe and efficient manner. I have answered all questions
to the best of my knowledge. Should further information be needed, you have my permission to ask the respective health care provider or
agency, who may release such information to you. I will notify the doctor of change in my health and medication.
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