Microsoft word - health history

Port Royal Oral Surgery, P.A.

ANSWER ALL QUESTIONS by circling Yes (Y) or No (N) All responses are kept confidential!

G. Insulin or Oral Anti-Diabetic drugs? . Y N H. Digitalis, Inderal, Nitroglycerin or other heart drugs. Y N
Are you taking or have you ever taken
Bisphosphonate for osteoporosis, multiple myeloma or 4. Are you now under a physician’s care for other cancers (Fosamax, Actonel, Boniva, Aredia,
Zometa) ? . Y N
ever had any serious illnesses,
any and all medications taken, including
operations or hospitalizations? If so, describe: . Y N prescription medications, diet drugs, over-the-counter mediations, herbal or holistic remedies, vitamins or
7. DO YOU HAVE OR HAVE YOU EVER HAD:
________________________________________________ A. Rheumatic Fever or Rheumatic Heart Disease? . Y N ________________________________________________ C. Cardiovascular Disease (Heart Attack, Heart Trouble, Heart Murmur, Coronary Artery Disease, 9. ARE YOU ALLERGIC TO OR HAVE YOU HAD AN
Angina, High Blood Pressure, Stroke, Palpitations, ADVERSE REACTION TO:
A. Local Anesthesia (Novocain, etc.)? . Y N D. Lung Disease (Asthma, Emphysema, Chronic B. Penicillin or other antibiotics? . Y N Cough, Bronchitis, Pneumonia, Tuberculosis, E. Seizures, Convulsions, Epilepsy, Fainting or G. Other allergies or reactions? Please, list . Y N F. Bleeding Disorder, Anemia, Bleeding Tendency, Blood Transfusion? Do you bruise easily? . Y N G. Liver Disease (Jaundice, Hepatitis)? . Y N 11. Is there any past history of Alcohol or Chemical Dependency or Emotional Disorder that may affect 12. Have you or an immediate family member had any problem associated with intravenous anesthesia? . Y N 13. Do you have any other disease, condition or O. Implants placed anywhere in your body problem not listed above that you think the doctor (Heart Valve, Pacemaker, Hip, Knee)? . Y N O. Radiation (X-ray) treatment for Cancer? . Y N 14. Do you wish to talk to the doctor privately P. Clicking or popping of jaw joint, pain near ear, difficulty opening mouth, grind or clench teeth? . Y N 15. FOR WOMEN ONLY
R. Any disease, drug or transplant operation A. Are you Pregnant, or is there any chance
that has depressed your immune system (HIV, etc)?.Y N 8. ARE YOU USING ANY OF THE FOLLOWING:
C. If you are using Oral Contraceptives, it is important
that you understand that antibiotics (and some other medications) may interfere with the effectiveness of oral C. Aspirin or drugs such as Motrin, Aleve, Ibuprofen? . Y N contraceptives. Therefore, you will need to use D. High Blood Pressure medications? . Y N mechanical forms of birth control for one complete cycle of birth control pills, after the course of antibiotics or cation is completed. Please consult with your 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 Heath History with my doctor.

Source: http://www.portroyaloralsurgery.com/Health%20History.pdf