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New health history revised 6-25

Portland Periodontics
PATIENT HEALTH HISTORY
Patient’s Name_________________________
ARE YOU USING ANY OF THE FOLLOWING:
A. Antibiotics? ……………………………………………Y N B. Anticoagulants (Blood Thinners)?.Y N Age__________ Date of Birth__________________________ C. Aspirin or drugs such as Aleve, Ibuprofen? ……….Y N D. High Blood Pressure medications? ……………….Y N Answer all questions by circling Yes (Y) or No (N)
E. Steroids (Cortisone, Prednisone, etc.)?. Y N 1. Are you in good health? .Y N F. Tranquilizers? . Y N G. Insulin or Oral Anti-Diabetic drugs? . Y N H. Digitalis, Inderal, Nitroglycerin or other heart 4. Are you now under a physician’s care for I. Bisphosphonate (Aredia, Zometa, Actonel, Boniva, If so, please explain ________________________________ J. Bisphosphonate Reclast Injection once a year.Y N ________________________________________________ K. Please list any and all medications you have taken within ________________________________________________ the PAST YEAR, including prescription medications, 5. PHYSICIAN’S NAME_______________________________
over-the-counter medications, herbal or holistic PHYSICIAN’S PHONE NUMBER_____________________
6. Have you ever had any serious illnesses or surgeries?
________________________________________________ 8. ARE YOU ALLERGIC TO OR HAVE YOU HAD AN
7. DO YOU HAVE OR HAVE YOU EVER HAD:
ADVERSE REACTION TO:
A. Local Anesthesia (Novocain, etc.)? . Y N B. Penicillin or other antibiotics? . Y N C. Cardiovascular Disease (Heart Attack, Heart C. Sedatives, Barbiturates, Sulfites?. Y N Trouble, Heart Murmur, Mitral Valve Prolapse, Rheumatic fever, Coronary Artery Disease, Angina, High Blood Pressure, Stroke, Palpitations, G. Other allergies or reactions? Please, list ………….Y N D. Lung Disease (Asthma, Emphysema, Chronic Cough, Bronchitis, Pneumonia, Tuberculosis, E. Seizures, Convulsions, Epilepsy, Fainting or How much per day? ________ How many Years?_________ 11. Is there any past history of Alcohol or Chemical F. Bleeding Disorder, Anemia, Bleeding Tendency, Dependency or Emotional Disorder that may affect 12. Do you use recreational drugs? List………………………Y N H. Liver Disease (Jaundice, Hepatitis A, B or C)? .Y N 13. Have you had any serious problems associated with ________________________________________________ 14. Do you have any other disease, condition or problem not listed above that you think the doctor 15. Do you wish to talk to the doctor privately O. Implants or artificial joints placed anywhere in your body (Heart Valve, Pacemaker, Hip, Knee)? .Y N P. Radiation (X-ray) or Chemo Therapy treatment for 16. FOR WOMEN ONLY
A. Are you Pregnant, or is there any chance
Q. Clicking or popping of jaw joint, pain near ear, difficulty opening mouth, grind or clench teeth?.Y N C. If you are using Oral Contraceptives, it is important
S. Any disease, drug or transplant operation that you understand that antibiotics (and some other that has depressed your immune system? .Y N medications) may interfere with the effectiveness of oral T. AIDS/HIV Positive…………………………………….Y N contraceptives. Therefore, you will need to use mechanical forms of birth control for one complete cycle of birth control pills, after the course of antibiotics or other medication is completed. Please consult with your physician for further guidance. I verify that the above is true and correct. I understand that the information I provide on this form is essential to protect me and
to ensure that proper care is provided. I will report any future changes in my health to Dr, Goldwyn as soon as possible. I have
read and understood each question, and I will discuss this history with Dr. Goldwyn prior to initiation of any treatment.

______________________
Signature of Person Completing Health History

Source: http://www.portlandperiodontics.com/patientforms/pper-health-history-form.pdf

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