Health History Update Step 1 of 4 25% CONFIDENTIAL PATIENT INFORMATIONDate(Required) MM slash DD slash YYYY Patient Name(Required)Your Email Address(Required) Home Phone(Required)Business/Cell Phone(Required)Address(Required) Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code OccupationBirth Date(Required) MM slash DD slash YYYY Sex(Required) Male Female SS #Relationship to Patient(Required)If completing this form for another person, your relationship to the patient.TUBERCULOSIS SCREENINGCheck if you have any of the following diseases or problems.If you answer YES to any of the below, please notify the front desk immediately. Active Tuberculosis Persistent cough greater than a 3 week duration. Cough that produces blood. Been exposed to anyone with Tuberculosis. DENTAL INFORMATIONDo your gums bleed when you brush or floss? Yes No Are your teeth sensitive to cold, hot, sweets or pressure? Yes No Have you had any periodontal (gum) treatments? Yes No Have you ever had orthodontic (braces) treatment? Yes No Have you used any teeth whitener? Yes No Are you happy with your smile's appearance? Yes No Do you suffer from dry mouth? Yes No Do you have jaw clicking, popping or discomfort? Yes No Do you clench or grind your teeth? Yes No Do you wear dentures or partials? Yes No Have you ever had a serious injury to your head or mouth? Yes No Is your home water fluoridated? Yes No Do you have sores or ulcers in your mouth? Yes No Do you participate in active recreational activities? Yes No Are you currently experiencing dental pain or discomfort? Yes No Have you had any problems associated with previous dental treatment? Yes No How did you hear about us?(Required) Facebook Google Website Mail Referring Dentist Other MEDICAL INFORMATIONPrimary Care Physician(Required)PhoneAre you under the care of a physician?(Required) Yes No If yes, reasoning?Have you had a serious illness, operation, or hospitalization in the past 5 years?(Required) Yes No If yes, what illness or condition?Are you taking any perscription or over-the-counter medications, vitamins, or supplements?(Required)If yes, please provide a copy. Yes No Has there been any change in your health within the past 2 years?(Required) Yes No If yes, what?Have you ever had artificial joint replacement/(prosthetic) heart valve?(Required) Yes No Date MM slash DD slash YYYY If yes, were there any complications?Are you taking osteoporosis or antiresorptive medications (Fosamax, Boniva, Prolia, Reclast, Xgeve, etc.)?(Required) Yes No Since 2001, have you been treated or scheduled for IV bisphosphonate therapy (Aredia, Zometa, Xgeva)?(Required) Yes No Do you bleed excessively after an injury or dental treatment?(Required) Yes No Do you use controlled substances?(Required) Yes No Do you use tobacco or nicotine products?(Required) Yes No Do you drink alcohol?(Required) Yes No Are you Pregnant? Yes No If yes, how many weeks?Are you currently nursing? Yes No Has a physician or previous dentist recommended antibiotics before dental treatment?(Required) Yes No If yes, please name the Physician/Dentist.Allergies (Check all that apply)(Required) Local anesthetics Aspirin Penicillin/other antibiotics Barbiturates/sedatives/sleeping pills Sulfa drugs Codeine/other norcotics Metals Latex Iodine Hay fever/seasonal allergies Animals Foods Other Please list other allergies.Medical Conditions (Check all that apply)(Required) Artificial heart valve Previous infective endocarditis Congenital heart disease Damaged heart valves Cardiovascular disease Angina Congestive heart failure Heart attack Heart murmur High blood pressure Low blood pressure Pacemaker Rheumatic fever Rheumatic heart disease Stroke Anemia Blood transfusion Hemophilia AIDS/HIV Arthritis Autoimmune disease Rheumatoid arthritis Systemic lupus erythematosus Asthma Bronchitis Emphysema Sinus trouble Tuberculosis Cancer/Chemotherapy/Radiation Chest pain upon exertion Chronic Pain Diabetes Type I or II Eating Disorder Gastrointestinal disease Acid reflux/GERD Ulcers Thyroid disease Glaucoma Hepatitis/liver disease Epilepsy Fainting spells/seaizures Neurological disorders Sleep disorder Mental health disorder Recurrent infections Kidney disease Night sweats Osteoporosis Persistent swollen glands Severe headaches/migraines Severe or rapid weight loss Sexually transmitted disease Excessive urination Other Please list any other disease, condition, or problem not listed above that you think we should know about. PERSON TO BE CONTACTED IN CASE OF EMERGENCYName(Required)Phone Number(Required)Relationship(Required)
