HEALTH HISTORY

Department of Oral & Maxillofacial Surgery

PATIENT NAME				TODAY’S DATE
	First MI Last
DATE OF BIRTH		AGE	SEX (Circle) Male Female		REFERRED BY

DESCRIBE WHY YOU CAME TO THE DOCTOR TODAY:

ALLERGIES TO:			HAVE YOU HAD ANY PREVIOUS:
YES	NO		YES	NO		YES	NO		YES	NO
		Penicillin			Operations (List)			Anesthesia Complications (Explain)			Cosmetic Surgery (List)
		Local Anesthesia
		Aspirin
		Other

List All The Medications/Drugs You Are Currently Taking		Primary MD Doctor:		Phone:
1	5	Primary Dentist:		Phone:
2	6	(Other Doctors)
3	7	Dr.	Specialty	Phone:
4	8	Dr.	Specialty	Phone:

HISTORY OF ILLNESS:

YES

NO

YES

NO

YES

NO

YES

NO

Eye Problems

Heart Murmur

Asthma

Blood Thinners

Glaucoma

Congenital Heart Disease

Cough

Frequent Nosebleeds

Ear Problems

Heart Surgery

Ulcers

Anemia

Sinus Trouble

Pacemaker

Liver Disease

Kidney Failure

Nasal Obstruction

Abnormal Heart Rhythm

Hepatitis

Diabetes

Dental Problems

High Blood Pressure

Cirrhosis

Thyroid Problems

Heart Trouble

Low Blood Pressure

Jaundice

Arthritis

Heart Attack

Shortness Of Breath

Seizures/Convulsion

Cancer Or Tumors

Angina (Chest Pain)

Lung Problems

Stroke

Radiation Treatment

Rheumatic Fever

Emphysema

Prolonged Bleeding

Chemotherapy

Frequent Bruising

Psychiatric Illnesses

ADDITIONAL QUESTIONS:

YES

NO

YES

NO

Do you have clicking or popping of jaw joint, pain near ear, difficulty opening mouth, grind or clench teeth?

Do you wear contact lenses?

Do you smoke or use smokeless tobacco?

Have you ever taken accutane?

Are you on a special diet?

Do you have any prosthetic joints?

Have you taken steroids within the last 3 months?

Do you or any of your family members have Sickle Cell Anemia or trait?

OTHER ILLNESSES:

WOMEN ONLY:

Are you pregnant? Date of last menstrual cycle:

Are you on birth control?

PARTENT OR GUARDIAN’S SIGNATURE:

PHYSICIAN’S COMMENTS:

Reviewed by Doctor:

Code #:

Date Reviewed: