• Health History

• Name
• Date
• Email

• Date if last health care exam:
• What was this exam for?

• Have you been hospitalized or had surgery? (Please check)

• Yes

  No

• If yes, reason:

• Are you currently receiving care?

• Yes

  No

• If yes, nature of care:

• Please list all the names and phone numbers of the physicians who are currently providing you care:

• 1.

• 2.

• 3.

• 4.

• For the following questions check yes or no. Your answers are for our records only and will be confidential. Please note that during your initial visit you will be asked some questions about your response. Our team may ask additional questions concerning your health.

• 	Yes No
  Blood Disorders?
  Arthritis, Rheumatism or other inflammatory disease?
  Asthma, COPD or other Lung Diseases
  Abnormal Bleeding from a cut?
  Cancer or Tumor?
  Diabetes
  Emphysema or other Respiratory/Lung Illnesses
  Epilepsy
  Fainting or Dizzy Spells
  Glaucoma
  Previous Bacterial Endocarditis
  Heart Valve (artificial) or Heart Transplant
  Congenital Heart Disease
  Heart Disease, Heart Attack, Heart Surgery, Angina
  Heart Stent? When placed?

• 	Yes No
  Hepatitis, Any Form
  Joint Replacement? When placed?
  Kidney Disease
  Liver Disease (including Jaundice)
  Sore/Enlarged Lymph Nodes
  Psychiatric Therapy
  Previous Biopsies
  Radiation or Chemotherapy Treatment
  Renal Dialysis
  Slow-Healing Mouth Sores
  Unintentional Weight Loss/Gain
  H.I.V. Infection/AIDS or ARC
  Venereal Disease
  Other Conditions
  Recurrent Illness

• Are you taking any of these medications?

• 	Yes No
  Pre-medication before dental treatment?
  Antacids?
  St. John's Wort or Kava-Kava?
  Dilantin® or Tegretol®

• 	Yes No
  Biaxin® (clarithromycin)
  Cardizem® (diltiazem) or Calan, Isoptin® (Veraoamil)?
  Barbiturates(any)
  Diflucan (flucoazole) or Sporonox (itraconazole)

• Have you been treated with Bisphosphonate drugs (Fosamax®, Aredia®, Zometa®, Actonel®, Boniva®, RECLAST) or PROLIA? If so, when did the treatment begin? When did the treatment end?

  Yes

  No

• Do you consume grapefruit juice, grapefruits or grapefruit extract?

• Yes

  No

• Please list any medications you are currently taking and dosages:

• 1.
• 3.
• 5.
• 7.

• 2.
• 4.
• 6.
• 8.

• Please list any dietary or herbal supplements you are taking, and for what purpose:

• 1.
• 3.
• 5.
• 7.

• 2.
• 4.
• 6.
• 8.

• Do you use recreational drugs?
• If so, which ones?