Southcarolinaendo.com

HEALTH HISTORY
Have you ever had any of the following diseases or medical problems?
(Please read thoroughly and circle “Yes” or “No”.)
Yes No Heart Attack/Stroke
Yes No Cancer/Chemotherapy
Yes No Heart Murmur/Rheumatic Fever
Yes No HIV+/AIDS
Yes No Heart Surgery/Pacemaker
Yes No Shingles
Yes No Heart Valve (Artificial)
Yes No Kidney Problems
Yes No Chronic Hepatitis
Yes No Sinus Problems
Yes No Anemia
Yes No Fever Blisters
Yes No High/Low Blood Pressure
Yes No Psychiatric Care
Yes No Severe Headaches
Yes No Diabetes
Yes No Epilepsy/Seizures/Fainting Spells
Yes No Tuberculosis (TB)
Yes No Drug/Alcohol Abuse
Yes No Sickle Cell Disease
Yes No Hemophilia/Abnormal Bleeding
Yes No Joint Prosthesis (Hips, Other)
Yes No Root Canal Treatment
Yes No Blood Transfusion
Have you ever experienced any serious medical conditions not listed above? If yes, please list: _____________________________________________________________________________________________ ___________________________________________________________________________________________________________ Are you currently under the care of any physician? If yes, please explain: _________________________________________________________________________________________ ___________________________________________________________________________________________________________ Are you presently taking any drugs prescribed by a physician or dentist? If yes, please list: _____________________________________________________________________________________________ ___________________________________________________________________________________________________________ Have you ever taken Bisphosphonates? □ Yes □ No
(Fosamax, Fosamax Plus D, Zometa, Didronel, Reclast, Boniva, Actonel, Aclasta, Aredia, Atelvia, Skelid)
Are you allergic to the following drugs?
Yes No Penicillin
Yes No Aspirin
Yes No Erythromycin
Yes No Tetracycline
Yes No Dental Anesthetics
Yes No Codeine
--------------------------------------------------------------------------------------------------------- Are you allergic to bleach? □ Yes □ No
Are you allergic to LATEX?
□ Yes □ No
□ Yes □ No
If yes, please list: _____________________________________________________________________________________________ ___________________________________________________________________________________________________________
Are you required to take antibiotics prior to dental treatment for artificial joints or heart defects?
Our office is committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC and the ADA.
WARNING: Birth control pills may be rendered ineffective by antibiotics.
Signature: ____________________________________________________ Date: ___________________________________

Source: http://www.southcarolinaendo.com/forms/health%20history.pdf