Alamomaxillofacial.com

YES (Y) OR NO (N). All responses are kept confidential.
Chief Complaint (reason for your visit):___________________ Clicking or Popping of the jaw joint,pain near ear, difficulty _____________________________________________________ opening mouth,grind or clech teeth?……………….
Are you in good Health?……………………………….
Sinus or nasal problems?………………………………. Y N Has there been any change in your general health Any disease,drugs or transplant operation that has in the past year?……………………………………….
depressed your immune system?…………………….
Date of last Physical Exam________________________________ Recurrent infections of any kind?…………………….
Are you now under a Physicians care for a particular ARE YOU USING OR TAKING ANY OF THE FOLLOWING: problem?………………………………………………. Y N Tagamet?……………………………………………… If so, please describe____________________________________ Thyroid medications?………………………………… _____________________________________________________ Antibiotics or sulfa drugs?…………………………….
_____________________________________________________ Anticoagulants (blood thinner(s))?…………………… Have you had any serious illnesses, operations or hospitalizations High Blood Pressure medicine?………………………. Y N If so, please describe____________________________________ Steroids (Cortisone, etc.)?……………………………… Y N _____________________________________________________ Tranquilizers (Valium, etc.)?…………………………… Y N Have you ever had any adverse effects from Dental Treatment? Insulin, Diabetese or similar drugs?……………………. Y N ……………………………………………………….
Digitalis, Inderal, Nitroglycerin, Calcium channel If so, please describe____________________________________ blockers, Procardia or other heart medicine?…………. Y N _____________________________________________________ Aspirin or ibuprofen (motrin, naprosyn, etc)?……….
DO YOU CURRENTLY HAVE OR HAVE YOU EVER HAD: If so, how much daily___________________________________ Rheumatic Fever or Rheumatic Heart Disease?…….
Marijuana or other "street drugs"?…………………….
Congenital Heart Disease?…………………………….
Antihistamines or decongestants (Seldane)?…………… Y N Cardiovascular Disease (heart trouble,heart attack,heart Herbal/Over-the-Counter medications, pills or drugs?… Y N murmur,coronary artery disease,angina,high blood pressure Are you taking any of the Bisphosphonate family of drugs stroke,palpitations,heart surgery or pacemaker)?…… (Aredia, Zometa, Fosamax, Actonel)?…………………. Y N Lung Disease (asthma,emphysema,chronic cough,bronchitis ARE YOU ALLERGIC TO OR HAVE HAD A REACTION TO: pneumonia,tuberculosis,shortness of breath,chest pain, Penicillin, Amoxicillin, cephalosporins or other severe coughing?……………………………………… antibiotics?…………………………………………….
Seizures,convulsions,epilepsy, fainting,psychiatric treatment Local anesthetic (Novacaine,etc)?…………………….
dizziness,nervous disorder or breakdown?………….
Barbiturates,sedatives etc?……………………………. Y N Bleeding Disorder,anemia,bleeding tendency,blood Aspirin or Ibuprofen?………………………………….
transfusion or do you bruise easily?……………………. Y N Codeine or other pain killers?………………………….
Liver Disease (jaundice,hepatitis)?……………………. Y N Latex or rubber products?…………………………….
Kidney Disease?……………………………………….
If yes, please describe___________________________________ Diabetes?………………………………………………. Y N Other allergies/reactions?…………………………………… Thyroid Disease (Goiter)?…………………………….
Please describe_________________________________________ Arthritis?…………………………………………….
Do you smoke or chew tobacco?………………………. Y N Stomach Ulcers or Colitis?…………………………… If so, how much daily?__________________________________ Glaucoma?…………………………………………….
Do you use alcohol?……………………………………. Y N Frequent or recurring mouth sores?……………………. Y N If so, how much daily?__________________________________ Implants placed anywhere in your body?…………….
Have you ever sought professional care for drug abuse, alcohlism, If so, please describe____________________________________ or emotional disorder?…………………………………. Y N _____________________________________________________ Do you have any other disease, condition or problem not listed Radiation (X-ray) treatment for Cancer?……………… Y N above that you think the doctor should know about?…. Y NIf so, please descibe_____________________________________ Have you had any serious problems associated with any previous Are you pregnant or planning pregnancy?…………….
dental treatment?………………………………………. Y N Are you taking birth control pills?…………………….
Have you or an immediate family member had any problems Are you taking hormone replacements?………………. Y N asscoiated with intravenous anesthesia?………………. Y NDo you wish to talk with the doctor privately aboutanything?………………………………………………. Y N I UNDERSTAND THE IMPORTANCE OF A TRUTHFUL HEALTH HISTORY TO ASSIST THE DOCTOR IN PROVIDING THEBEST CARE POSSIBLE. I UNDERSTAND THAT I WILL HAVE THE OPPORTUNITY TO DISCUSS MY HEALTH HISTORY WITH MY DOCTOR.
_____________________________________________________________________________________ Signature of person completing Health History

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