Patient Healthy History Form

Patient Healthy History Form

Patient Healthy History Form

Patient Healthy History Form

Patient Healthy History Form

About Cossich Family Dentistry

Cossich Family Dentistry provides the highest quality, compassionate eye care to ensure your family enjoy a long, happy, and healthy life.

Patient Name
Date
Primary reason for this appointment:

Dental History

Do you have a specific dental problem? If so, describe
Circle One
Do you have dental examinations on a routine basis? Date of last visit

Do you have dental examinations on a routine basis? Date of last visit

Do you think you have active decay or gum disease?

Do you brush and floss on a routine basis? Discuss

Do your gums ever bleed? Discuss

Do you like your smile? If not, why?

Does food get caught between your teeth? Any loose teeth?

Do you want to keep your remaining teeth?

Do you ever have clicking, popping or discomfort in the jaw joint? Do you brux or grind?

Have your past experiences in a dental office always been positive?

Do you smoke or chew tobacco? Any sores or growths in your mouth? Discuss

Name of previous dentist (Optional)

Date of last full mouth x-rays (Sixteen small films or a panoramic)

Medical History

Are you under a physician’s care now? If so, why?
Who?
Phone
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Have you ever been hospitalized or had a major operation? Discuss.
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Are you taking any medications, aspirin, vitamins, herbals, pills or drugs? What?
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Are you on a special diet? Discuss
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Are you allergic to any medications or substances? Please check box below.
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Women (Please check as appropriate)
Do you now have or have you ever had any of the following? Do you take any of these medicines? Please check appropriate boxes. If you answered yes to any condition followed by a star (*), please call the office prior to your appointment as premedication or changes in medication may be required.
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Heart Disease/Surgery*
Heart Murmur or
Defect*
Irregular Heart Beat
Angina/Chest Pain
Heart Attack/Failure
Congenital Heart Disorder*
Mitral Valve Prolapse*
Scarlet Fever
Rheumatic Fever*
Artificial Heart Valve*
Heart Pace Maker*
Pulmonary Shunt*
High Blood Pressure
Low Blood Pressure
Bacterial Endocarditis*
Unexplained Fever
Bruise Easily/Blood Disease
Anemia
Coronary Stent*
Excessive Bleeding
Sickle Cell Disease
Hemophilia
Methomoglobinemis
Leukemia
Recent Blood Transfusion
Swelling of Limbs
Lung Disease
Breathing Problem
Shortness of Breath
Frequent Couth
Hay Fever
Sinus Trouble
Asthma
Bloody Sputum
Emphysema
Tuberculosis
Cancer
X-ray Treatments (Radiation)
Chemotherapy
Osteoporosis
Bisphosphonates
Osteonecrosis of Jaw
Aredia I.V. Reciast I.V
Zometa I.V
Fosamax, Actonel, Boniva
Stomach/intestinal Disease
Ulcers
Diabetes
Excessive Thirst
Hypoglycemia
Liver Disease
Hepatitis A (Infectious)
Hepatitis B or C
Protease Inhibitor
Night Sweats
Yellow Jaundice
Kidney Problems
Renal Dialysis
Thyroid Disease
Parathyroid Disease
Arthritis/Gout
Rheumatism
Pain in Jaw Joints
Cortisone Medicine
Artificial Joint*
Sexually Transmitted Disease
AIDS
HIV Positive
Genital Herpes
Drug Addiction
Alcoholism
Tattoos/Body Piercing
Sleep Apnea
Cold Sores
Fever Blisters
Herpes
Stroke
Convulsions
Epilepsy or Seizures
Fainting or Dizziness
Glaucoma
Tumors or Growths
Nervousness
Psychiatric Care
Alzheimer’s Disease
Allergies (Medicines)
Allergies (Pollen/Dust)
Hives or Rash
Need Premedication?
Ever taken fen-phen?*
Cochlear implants?
Have you ever had any other serious illness not listed above? Discuss

Do you wish to talk to the dentist privately about any problem or concern?
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To the best of my knowledge all of the preceding answers are correct. I shall inform the dentist/staff at the next appointment of any changes in my health status or if there are any changes in the medications I am taking.

Signature:
Date:
Reviewed by Doctor:
Date:
BP:
Pulse:
History Review and Significant Findings

Medical Updates

I have read my medical history dated and confirm that it adequately states past and present conditions.
Date:
Exceptions:
Patient’s Signature:
BP:
Pulse:
Reviewed By: