Patient Health History - Child | Giordano Family Dentistry

Patient Health History

Name

First Last

Birth date

Phone (Home)

Phone (Work)

For the following questions, please select yes or no, whichever applies

1. Are you in good health?

Yes
No

2. Has there been any change in your general health in the past year?

Yes
No

3. Are you currently under the care of a physician?

Yes
No

If so, for what condition(s)?

4. Have you had any serious illness, operation, or been hospitalized in the past 5 years?

Yes
No

5. Do you have or have you had any of the following diseases of problems (please check ones that apply)?

Yes
No

A. Rheumatic Fever, Rheumatic Heart Disease, Artificial Heart Valves?

Yes
No

B. Congenital Heart Lesions, Heart Murmur, Mitral Valve Prolapse?

Yes
No

C. Cardiovascular Disease (heart trouble, heart attack, angina, coronary insufficiency, coronary occlusion, high blood pressure, arteriosclerosis, stroke?

Yes
No

i. Chest pain upon exertion?

Yes
No

ii. Are you ever short of breath after mild exercise or when lying down?

Yes
No

iii. Do your ankles swell?

Yes
No

iv. Do you have a pacemaker?

Yes
No

D. Tuberculosis?

Yes
No

E. Persistent cough or cough that produces blood?

Yes
No

F. Respiratory problems, emphysema, bronchitis?

Yes
No

G. Asthma, hay fever, sinus trouble?

Yes
No

H. Fainting spells or seizures?

Yes
No

I. Diabetes?

Yes
No

J. Hepatitis, Jaundice, or Liver Disease?

Yes
No

K. Aids or HIV Infection?

Yes
No

L. Sexually Transmitted Disease?

Yes
No

M. Thyroid problems?

Yes
No

N. Arthritis, Inflammatory Rheumatism (painful swollen joints)?

Yes
No

O. Stomach problems?

Yes
No

P. Kidney Trouble?

Yes
No

Q. Low blood pressure?

Yes
No

R. Epilepsy?

Yes
No

S. Psychological disorders?

Yes
No

T. Cancer?

Yes
No

U. Join replacement (pins, plates or posts)?

Yes
No

6. Have you had abnormal bleeding associated with previous extractions, surgery or trauma?

Yes
No

A. Have you ever required a blood transfusion?

Yes
No

7. Do you have any blood disorders such as anemia?

Yes
No

8. Have you had surgery or x-ray treatment for a tumor, growth, or other condition of the head or neck?

Yes
No

9. Are you taking any of the following drugs or medications?

A. Antibiotics (penicillin, erythromycin, sulfa drugs)?

Yes
No

B. Antihistamines/Allergy Drugs?

Yes
No

C. Aspirin?

Yes
No

D. Tranquilizers?

Yes
No

E. Insulin?

Yes
No

F. Cortisone/Steroids?

Yes
No

G. Heart Medicine?

Yes
No

H. Blood Thinners/Anticoagulants?

Yes
No

I. Blood Pressure Medication/Nitroglycerin?

Yes
No

J. Others?

Yes
No

10. Are you allergic or have you reacted to adversely to:

A. Local Anesthetics (e.g. novocaine, carbocaine)?

Yes
No

B. Penicillin or other antibiotics?

Yes
No

C. Sulfa drugs?

Yes
No

D. Barbiturates?

Yes
No

E. Aspirin?

Yes
No

F. Codeine or other narcotics?

Yes
No

G. Others?

Yes
No

11. Do you use tobacco in any form?

Yes
No

If so, what type(s)

Yes
No

12. Do you have any disease, condition or problem not listed above that you think we should know about?

Yes
No

If so, please describe

Women

Are you pregnant?

Yes
No

Do you have any problems with your menstrual period?

Yes
No

Are you nursing?

Yes
No

Are you taking birth control pills?

Yes
No

Physician Name

Physician Address

Street Address Address Line 2 City State ZIP Code

Physician Phone

I certify that I have read and understand the above. I acknowledge that my questions, if any, about the inquiries set forth above have been answered to my satisfaction. I will not hold my dentist, or any other member of the staff, responsible for any errors or omission that I may have made in the completion of this form.

Agree to terms?
Yes, I agree.
No, I disagree.

Electronic Signature (E-Signature) Agreement

By selecting the "I Accept" button, you are signing this Release of Records electronically. You agree your electronic signature is the legal equivalent of your manual signature on this Release of Records. You also agree that no certification authority or other third party verification is necessary to validate your E-Signature and that the lack of such certification or third party verification will not in any way affect the enforceability of your E-Signature. You also represent that you are authorized to sign this Release of Records for all persons listed on this form.*
I Accept

Electronic Signature:

Name*
First Last

Today's Date*

Name
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