Nocerino Health History

Alternative text

PATIENT HEALTH HISTORY

Patient First Name

Patient Last Name

Birth Date

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.

Are you under the care of a physician?

Yes No

If yes, please describe

Have you ever been hospitalized or had a major operation?

Yes No

If yes, please describe

Have you ever had a serious head or neck injury?

Yes No

If yes, please describe

Are you taking any medications, pills, or drugs?

Yes No

If yes, please list

Do you take, or have you taken, Phen-Fen or Redux?

Yes No

If yes, please describe

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

Yes No

If yes, please describe

Do you use tobacco?

Yes No

ARE YOU ALLERGIC TO ANY OF THE FOLLOWING?

Aspirin

Yes No

Metal

Yes No

Penicillin

Yes No

Codeine

Yes No

Acrylic

Yes No

Latex

Yes No

Sulfa Drugs

Yes No

Local Anesthetics

Yes No

Do you have any other allergy not listed above?

Yes No

If yes, please list

Do you use controlled substances?

Yes No

If yes, please list

FOR WOMEN ONLY

Are you...

Pregnant/Trying to get pregnant?

Yes No

Nursing

Yes No

Taking Oral Contraceptives?

Yes No

DO YOU HAVE OR HAVE YOU EVER HAD ANY OF THE FOLLOWING?

AIDS/ HIV Positive

Yes No

Alzheimer’s Disease

Yes No

Anaphylaxis

Yes No

Anemia

Yes No

Angina/Chest Pains

Yes No

Arthritis/Gout

Yes No

Artificial Heart Valve

Yes No

Artificial Joint

Yes No

Asthma

Yes No

Blood Disease

Yes No

Blood Transfusion

Yes No

Bruise Easily

Yes No

Cancer

Yes No

Chemotherapy

Yes No

Cold Sores/Fever Blisters

Yes No

Congenital Heart Defect

Yes No

Cortisone Medicine

Yes No

Dementia

Yes No

Diabetes

Yes No

Drug Addiction

Yes No

Easily Winded

Yes No

Emphysema

Yes No

Epilepsy or Seizures

Yes No

Excessive Bleeding

Yes No

Fainting Spells/Dizziness

Yes No

Heart Attack/Failure

Yes No

Heart Murmur

Yes No

Heart Pacemaker

Yes No

Heart Trouble/Disease

Yes No

Hemophilia

Yes No

Hepatitis A

Yes No

Hepatitis B or C

Yes No

Herpes

Yes No

High Cholesterol

Yes No

High Blood Pressure

Yes No

Hypoglycemia

Yes No

Irregular Heartbeat

Yes No

Kidney Problems

Yes No

Leukemia

Yes No

Liver Disease

Yes No

Low Blood Pressure

Yes No

Lung Disease

Yes No

Mitral Valve Prolapse

Yes No

Osteoporosis

Yes No

Pain in Jaw Joints

Yes No

Parathyroid Disease

Yes No

Radiation Treatments

Yes No

Recent Weight Loss

Yes No

Renal Dialysis

Yes No

Rheumatic Fever

Yes No

Rheumatism

Yes No

Scarlet Fever

Yes No

Sickle Cell Disease

Yes No

Sinus Trouble

Yes No

Stomach/Intestinal Disease

Yes No

Stroke

Yes No

Swelling of Limbs

Yes No

Thyroid Disease

Yes No

Tuberculosis

Yes No

Tumors or Growths

Yes No

Ulcers

Yes No

Yellow Jaundice

Yes No

Have you ever had any serious illness not listed?

Yes No

If yes, please list below.

COMMENTS:

Form Completion

To the best of my knowledge, the questions on this form have been accurately answered. 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.

Signature of Patient, Parent or Guardian

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