Rolfedentistry.com

Rolfe Family & Cosmetic Dentistry
Health History
Patients Name _________________________________________________________ Doctors Notes
Are you under a physicians care? Y / N Since When? __________ Why? _____________________ Physician Name ____________________________________________________________________ Address __________________________________________________ Phone _________________ When was your last complete Physical Exam? ____________________________________________ Are you taking any medications? If yes, please list _____________________________ Are you allergic to medications or substances? If yes, please list __________________ Do you have any other allergies? If so, please list _____________________________ Do you have any problems with penicillin, antibiotics, local anesthetics, or other medications? If so, please list_________________________________________ Are you sensitive to any metals or latex? If so, please note ______________________ Are you pregnant, or suspect you may be? …………………………………………………. Have you ever been treated for, or told you have heart disease? ………………………. Do you have a pacemaker or an artificial heart valve implant? ………………………. Have you ever had rheumatic fever? ………………………………………………………. Are you aware of any heart murmurs? ……………………………………………………… Do you have high or low blood pressure? …………………………………………………. Have you ever had a serious illness or major surgery? If yes, please list ____________ Have you ever had radiation or chemotherapy for a tumor or other condition? … Do you have soreness, clicking of popping in your jaw joint? ……………………………. Do you have any artificial joints, hips, or prosthesis? ………………………………… Do you have any blood disorders, such as anemia, leukemia, hemophilia, etc? If so, please list ____________________________________________________________ Have you ever bled excessively after being cut or injured? ………………………………. Do you have any kidney problems? …………………………………………………………. Are you diabetic? If yes, what type? _______________________________________ Are you HIV positive? …………………………………………………………………………. Have you had or do you test positive for hepatitis? If yes, what type? ____________ Do you or have you had tuberculosis? ………………………………………………………. Do you smoke, chew, use snuff, or any other form of tobacco? ………………………… Do you habitually use controlled substances? ……………………………………………… Have you ever been told to take antibiotics before any dental treatment? ……………. Have you ever taken any of the following Bisphosphonates medication: fosamax (i.e.,alendronat), Actonel (i.e., risedronate), aredia (i.e., pamidronate), bonefos (i.e., Clodronate), boniva (i.e., ibandronate), didronel (i.e., etidronate), ostac (i.e., pamidronate), bonefos (i.e., tiludronate), zometa, (i.e., zoledronic acid) etc. If yes, please specify ______________________________________________________________ Have you ever had cancer in the bone, or any other bone disease? If yes, please specify _____________________________________________________________________ Is there anything else we should know about your health that was not covered on this form? If yes, please explain _____________________________________________ When was your last dental exam cleaning? _____________________________________________ * I hereby authorize treatment and the use of nitrous oxide, anesthesia, oral sedation, and/or other medication necessary for dental treatment. The parent or guardian is required to remain in the dental office during their Childs treatment. Initial Visit Patients/Guardians signature ____________________________________________________ Date ___________________

First Update any changes _________________________________________________________________________________________
Patient's (parent) Signature: _______________________________________________________________ Date: ___________________
Second Update any changes _______________________________________________________________________________________
Patient's (parent) Signature: _______________________________________________________________ Date: ___________________
Third Update any changes _________________________________________________________________________________________
Patient's (parent) Signature: ________________________________________________________________ Date: __________________

Source: http://www.rolfedentistry.com/forms/Medical%20History.pdf