HEALTH HISTORY


Patient Name:

Date
General Dentist
Last Visit
Physician's Name
Ph. #
Are you now being treated by a physician?
HAVE YOU HAD ANY ILL EFFECTS FROM ANY OF THE FOLLOWING?
Local anesthetic.............
Penicillin...........................
Erythromycin.....................
Amoxicillin........................
Aspirin................................
Codeine.................................
Sulfa.......................................
Latex......................................
Any other drug.......................
LIST


Are you taking any medication to thin your blood...................................
Have you had any problem with abnormal bleeding...............................
Are you having any form of treatment for cancer......................................
Do you wear a pacemaker............................................................................
Have you been tested for HIV....................................................................
If so, the results were..........................................................................
Are you required to take Pre-Med prior to any dental appointments.....
If yes, was it taken today...............................................................................
HAVE YOU EVER HAD...
Heart trouble........................
Heart surgery.......................
Heart valve problems.........
History of heart murmur...
Rheumatic fever..................
Hepatitis................................
Kidney or liver disease.......
Artificial joint placements....
Tuberculosis..........................
Arthritis....................................
Epilepsy or seizures.............
Diabetes.................................
Tumor or malignant growth.
High/Low blood pressure...................................................................
Have you had surgery in the past 2 years................................................
If yes, please describe
Radiation Treatment to your Head or Neck.............................................
Are you currently having any chemo therapy............................................
If you smoke, how many packs a day?
Female: are you pregnant? Delivery date

Patient signature
Dr./Hygiene witness signature
Date

FOR OFFICE USE ONLY

U.D.

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PHARMACY
LIST MEDICATIONS BELOW:
IF YOU'RE NOT TAKING ANY MEDICATIONS, PLEASE LEAVE THE LINES BELOW BLANK.
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Patient Name:

Date

Please select the office you wish to be seen at:

West Bend 1305 Chestnut Street, West Bend, WI 53095

Greenfield 8405 W. Forest Home Avenue, Greenfield, WI 53228