Microsoft word - np form 2 - health history.docx

Answer all questions by circling Yes or No H. Digitalis, Inderal, Nitroglycerin or other heart drug? … 2. Has there been any change in your general health I. Are you taking or have you ever taken in the past year? …………………………………………………………… For osteoporosis, multiple myeloma, or other cancers 3. Date of your last physical exam______________ (Fosamax, Actonel, Boniva, Aredia, Zometa)? ………. 4. Are you now under a physician’s care for J. Controlled substances or recreational drugs …………. a particular problem? …………………………………. K. Please list all medications taken, including prescription medications, diet drugs, over-the-counter 5. Have you ever had any serious illnesses, herbal or holistic remedies, vitamins or minerals in the operations or hospitalizations? ………………………… ARE YOU ALLERGIC TO OR HAVE YOU HAD AN ADVERSE A. Rheumatic Fever or Rheumatic Heart Disease? ……. B. Congenital Heart Disease? …………………………. A. Local anesthesia (Novocaine, etc)? …………………. C. Cardiovascular Disease (heart attack, heart trouble, B. Penicillin or other antibiotics? ………………………… heart murmur coronary artery disease, angina, C. Sedatives, barbituates? ………………………………. high blood pressure, stroke, palpitations, D. Aspirin or Ibuprofen? …………………………………. heart surgery, pacemaker? …………………………. E. Codeine or other pain killers? …………………………. D. Lung disease (asthma, emphysema, chronic F. Latex or rubber products? ……………………………. Shortness of breath, chest pain, severe coughing? . G. Sulfa drugs? ……………………………………………. E. Seizures, convulsions, epilepsy, fainting or dizziness? H. Metals? ………………………………………………… F. Bleeding disorder, anemia, bleeding tendency, I. Other allergies or reactions? …………………………… blood transfusion? …………………………………. J. Do you smoke or chew tobacco? ……………………… G. Do you bruise easily? ………………………………… H. Liver Disease (Jaundice, Hepatitis)? ………………… K. Is there any past history of alcohol or chemical I. Kidney Disease? ………………………………………. dependency or emotional disorder that may affect the J. Diabetes? ……………………………………………. care we provide you? …………………………………………………… K. Thyroid Disease (Goiter)? ……………………………. L. Have you had any serious problems associated with L. Arthritis? ……………………………………………… any previous dental treatment? …………………………………… M. Stomach Ulcers or Colitis? …………………………. M. Have you or an immediate family member had any N. Glaucoma? …………………………………………… problem associated with intravenous anesthesia? ………. O. Osteoporosis? ………………………………………. N. Do you have any other disease, condition or problem P. Implants placed anywhere in your body (heart valve, not listed above that you think the doctor should know pacemaker, hip, knee)? ……………………………. about? ………………………………………………………………………… Q. Radiation (x-ray) treatment for cancer? ……………. O. Do you wish to talk to the doctor privately about R. Clicking or popping of jaw joint, pain near ear, anything? ……………………………………………………………………. difficulty opening mouth, grind or clench your teeth? S. Sinus or nasal problems? ……………………………. T. Any disease, drug or transplant operation that A. Are you pregnant or is there any chance you might depressed your immune system? …………………… be pregnant? ………………………………………………………………. B. Are you nursing? ………………………………………. C. If you are using oral contraceptives, it is important A. Antibiotics? …………………………………………. you understand that antibiotics ( and some medications) B. Anticoagulants (blood thinners)? …………………. may interfere with the effectiveness of oral C. Aspirin or drugs such as Motrin, Aleve, Ibuprofen? . contraceptives. Therefore, you will need to use D. High blood pressure medications? …………………. mechanical forms of birth control for one complete cycle E. Steroids (Cortisone, etc.)? …………………………. of birth control pills after the course of antibiotics is F. Tranquilizers? ………………………………………. completed. Please consult your physician for further G. Insulin or Oral Anti-Diabetic drugs? ………………… I UNDERSTAND THE IMPORTANCE OF A TRUTHFUL HEALTH HISTORY TO ASSIST THE DOCTOR IN PROVIDING THE BEST CARE POSSIBLE. I HAVE HAD THE OPPORTUNITY TO DISCUSS MY HEALTH HISTORY WITH MY DOCTOR. Signature of person completing health history

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