Health history.xlsx

REASON FOR VISIT: List in order of importance to you.
ALLERGIES: List any allergies to medications and / or foods
MEDICINES you are taking NOW. Include herbs, prescriptions, over-the-counter drugs, and vitamins.
Medication
CURRENT SYMPTOMS: Do you have any of the following symptoms? Please complete ALL
If yes , how often? (circle one)
OTHER SYMPTOMS NOT LISTED:
IMMUNIZATIONS & TESTS:
What vaccinations do you know you have received in the past as an adult OR child? Check & provide date.
I have received my childhood vaccinations in the U.S.   YES Have you ever had a positive TB skin test? NO / YES If yes , Chest X-ray result: Normal Abnormal
Have you ever been treated for TB? NO / YES
If yes , date of treatment:
Length of treatment: _________months.
PAST MEDICAL HISTORY:
Do you have, or have you ever had in the past, any of the following conditions?
Check each box “yes” or “no”. No straight lines please. Complete ALL.
Does food or floss catch between your teeth? Have you had periodontal (gum) treatments? How do you feel about your smile?Date of last dental exam: Are you taking or scheduled to begin taking alendronate (Fosamax®) OR risedronate (Actonel®) Since 2001, were you treated or are you presently scheduled to begin treatment with the intravenousbisphosphonates (Aredia® or Zometa® ) for bone pain, hypocalcaemia or skeletal complicationsresulting from Paget's disease, multiple myeloma or metastatic cancer? If yes , date treatment began:
Has a physician/dentist recommended that you take antibiotics prior to your dental treatment? If yes , name of physician/dentist:
Do you have any other disease, condition or problem that you think I should know about? PREVIOUS SURGERIES OR HOSPITALIZATIONS:
YEAR
FAMILY HISTORY:
Has any of your family / blood relatives ever had any of the following? SEXUAL HISTORY: Check one
Yes, had sexual activity in the past year.
Last sexual relations was ______ months/years ago. Sexually active with (Check all that apply ): Men Women Both Paid for sex or ProstituteDoes your sexual partner have other sexual partners? No  Yes I don’t know / maybeHave you had a sexual partner who has had sex with: Have you OR your sexual partner(s) had any infections related to sex? No Yes, specify:Birth Control method you use now OR have used in the past: (Check all that apply) Have any birth control methods caused you problems? No Yes, explain:What method of birth control are you using currently? FEMALES ONLY:
Age of first period?
Maximum # pads / tampons used in 24 hours? Did your mother take D.E.S. (a hormone) when she was pregnant with you? NO / YES / Unknown
REPRODUCTIVE HISTORY:
Have you ever been pregnant? NO / YES
HABITS: Do you need assistance for DAILY ACTIVITIES?
EXERCISE:
Do you exercise regularly? NO / YES If yes, type and frequency (min. per day / week):
Do you have, or have you ever had, an eating disorder or special eating problems? NO / YES
If yes , please explain:
DIET: Current Dietary Intake:
ANNUAL EXAM (HISTORY UPDATE AND REVIEW):
Signature:
This form was completed on: (Today’s date)
Friend / Relative: (Name / Relation) Patient signature:
Reviewed by:
NOTE: Provider and patient are encouraged to discuss all relevant patient health issues prior to treatment.
I certify that I have read and understand the above and that the information given on this form is accurate. I under-stand the importance of a truthful health history and that my doctor/dentist will rely on this information for treatingme. I acknowledge that my questions about inquiries set forth above have been answered to my satisfaction. I willnot hold my medical or dental provider or any member of the staff responsible for any action they take or do not takebecause of errors or omissions that I may have made in the completion of this form.

Source: http://www.snahc.org/snahc/wp-content/uploads/2009/09/Health-History.pdf