HEALTH HISTORY

Name

Date

Age

Birthday

I. What is the reason for your visit?

A. History of Illness

1. How long has the condition been present?

2. Which body area(s) are affected?

3. Have you had this condition previously?

4. Does your condition cause you symptoms?

If no symptoms proceed to section B.

5. Please describe your symptoms (pain, burning, itching, stabbing, puffiness, etc.)

6. What makes your symptoms better?

7. What makes your symptoms worse?

B. System Review

1. Is the condition causing weight loss, fever or affecting your general health?

If yes, please explain

2. Please check any of the following body areas if they are affected by the condition.

Eyes

Ears

Nose

Mouth

Throat

Muscles

Joints

3. Has the condition caused any enlarged lymph nodes?

C. Family History

1. Do any family members have the same or similar condition?

2. Which family members?

II. Past Medical History

A. Allergies

1. Please list any allergies to medications

2. Are you allergic to latex?

Yes No

3. Do you have any allergies to anesthetics?

Yes No

B. Please list any chronic medical conditions

C. Please list any surgeries:

Cancer: Type

Organ Transplant: Type

E. Surgical

1. Have you ever been told that you should receive antibiotics prior to teeth cleaning, dental procedures or surgery?

Yes No

2. Do you have any prosthetic (artificial) joints?

Yes No

3. Do you have a history of rheumatic fever or an abnormal heart valve?

Yes No

4. Do you have an artificial heart valve?

Yes No

5. Do you have a pacemaker or defibrillator?

Yes No

6. Do you have a history of hepatitis?

Yes No

7. Do you have a history of AIDSIHIV or immunosuppression?

Yes No

8. Do you have a bleeding disorder?

Yes No

9. Do you take Coumadin (Warfarin)?

Yes No

Last Dose

10. Do you take aspirin?

Yes No

Last Dose

F. Dermatologic

1. Have you ever had a skin cancer?

Yes No

If yes, please check type

Basal Cell

Squamous Cell

Melanoma

Don't Know

Location

2. Is there a family history of skin cancer?

Yes No

Relationship

Type of skin cancer (Please check)

Basal Cell

Squamous Cell

Melanoma

Don't Know

3. Do you have a history of atopic dermatitis or eczema?

Yes No

I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my medical status.

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