Health History - Cala Hills Endo
Health History
Patient Name: ______________________________________
Physician’s Name ____________________________________________
Date of last visit (if known) ______________________________________
Abnormal Bleeding Yes No Radiation Treatment Yes No
AIDS Yes No Recreational drug use Yes No
Alcoholism Yes No Rheumatic Fever Yes No
Scarlet Fever Yes No
Anemia Yes No Sinus Trouble Yes No
Arthritis/Rheumatism Yes No Shortness of
Artificial Heart Valve Yes No breath Yes No
Artificial Joints Yes No Skin Rash Yes No
Asthma Yes No Stroke Yes No
Back Problems Yes No Swelling of feet/ankles Yes No
Blood Disease Yes No Swollen neck glands Yes No
Cancer Yes No Taking birth control Yes No
Chemotherapy Yes No Thyroid problems Yes No
Congenital Heart Tonsillitis Yes No
Lesions Yes No Tuberculosis Yes No
Cortisone Tx Yes No Tumor or growth on
head or neck Yes No
Ulcer Yes No
Cough, persistent Venereal Disease Yes No
or bloody Yes No Weight loss, unexplained Yes No
Diabetes Yes No
Emphysema Yes No Current Medications:
Heart Murmur Yes No ___________________________
Hepatitis Type __ Yes No ___________________________
Herpes Yes No ___________________________
High Blood Pressure Yes No ___________________________
HIV Positive Yes No Allergies (ex. antibiotics, latex, codeine):
Kidney Disease Yes No ____________________________
Liver Disease Yes No ____________________________
Mitral Valve Prolapse Yes No ____________________________
Nervous Problems Yes No ____________________________
Other Medical Conditions not listed: _____________________________________
______________________________________________________________________
Do you normally take antibiotic prophylaxis prior to dental treatment? Yes No
(for artificial joints, hip replacement, heart valve etc.)
For what reason? ________________________________________________
Women:
Pregnant Yes/No Due Date ______________ Nursing Yes/No
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