Health history form

WELCOME!
HEALTH HISTORY
Dellin R. Bakkum, DDS
Please complete BOTH sides.

Date:_______ Name:_____________________________________________ Phones: _____________ Last Medical Exam:_________
Your Physician:_____________________________ Phone:_________ Second Physician:___________________ Phone:_________
Were you hospitalized in the last 5 years?
Reason(s)____________________________________________

Have you had surgery in the last 5 years?
Procedure(s)_________________________________________

Are you currently under medical care?
For_________________________________________________

For the following questions, please circle no or yes. 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 responses. Our team may ask additional questions concerning
your health.
Arthritis, Rheumatism or other inflammatory disease? Abnormal Heart or Previous Bacterial Endocarditis? Heart Valve (artificial) or Heart Transplant Heart Disease, Heart Attack, Heart Surgery? Please list any medications you are currently taking, and for what purpose:
Medication and Dose
Reason You Are Taking It
(Doctor's Use) Dental Implications

Please list any dietary or herbal supplements you are taking, and for what purpose:
Supplement
Reason You Are Taking It
(Doctor's Use) Dental Implications
Please complete side 2. Thank you!
Are you taking any of these medications?

Tagamet (Cimetidine) or Prilosec (Omeprazole)? No Yes Diltiazem (Cardizem) or Verapamil (Calan, Isoptin)? No Yes Fluconazole (Diflucan) or Itraconazole (Sporonox)? No Yes Do you eat grapefruit or drink grapefruit juice? Have you ever taken any prescription drugs (such as fen-phen) for weight loss? Have you ever been treated with a bisphosphonate drug (Fosamax, Aredia, Zometa, Actonel, Boniva)? If so, when No Yes did the treatment begin? When did the treatment end?
Women:
Is there a chance that you might become pregnant in the near future?
Have you had a bad reaction to, or are you allergic to:

Tobacco, Alcohol, Drugs
Do you use tobacco? If yes, circle type: smoke chew . How much per day? For how long? Do you consume alcohol? If yes, approximately how many alcoholic beverages per week? Do you use any mood altering drugs other than those previously listed?
Blood Pressure
Have you ever received a diagnosis of "high blood pressure"? What is your normal blood pressure (systolic/diastolic)? Pulse Today: SpO2 Today: Blood Pressure Today:
Weight and Diet Considerations
Sugar in your diet (circle one): none slight moderate high ____________________________________________ Patient (print name)
Patient Signature
Date

Dellin R. Bakkum, DDS
____________________________________________
________________
Doctor
Doctor Signature
Date
DOCTOR'S USE ONLY---------------------------------------------------------------------------------------------------------------------------------------
Comments and Significant Findings:_________________________________________________________________________________
______________________________________________________________________________________________________________ ______________________________________________________________________________________________________________ Dental Management Considerations:_________________________________________________________________________________ ______________________________________________________________________________________________________________

Source: http://greenvalleydentalcare.com/wp-content/uploads/2014/02/Health-History-Form.pdf