Health History Template
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1HEALTH HISTORY
MetLife
University of the Pacific
English
Patient Name:
Patient Identification Number:
Birth Date:
I. CIRCLE APPROPRIATE ANSWER (leave Blank if you do not understand question):
1.
Yes
No
Is your general health good?
2.
Yes
No
Has there been a change in your health within the last year?
3.
Yes
No
Have you been hospitalized or had a serious illness in the last three years?
If YES, why?
4.
Yes
No
Are you being treated by a physician now? For what?
Date of last medical exam?
Date of last Dental exam
5.
Yes
No
Have you had problems with prior dental treatment?
6.
Yes
No
Are you in pain now?
II. HAVE YOU EXPERIENCED:
7.
Yes
No
Chest pain (angina)?
18.
Yes
No
Dizziness?
8.
Yes
No
Swollen ankles?
19.
Yes
No
Ringing in ears?
9.
Yes
No
Shortness of breath?
20.
Yes
No
Headaches?
10.
Yes
No
Recent weight loss, fever, night sweats?
21.
Yes
No
Fainting spells?
11.
Yes
No
Persistent cough, coughing up blood?
22.
Yes
No
Blurred vision?
12.
Yes
No
Bleeding problems, bruising easily?
23.
Yes
No
Seizures?
13.
Yes
No
Sinus problems?
24.
Yes
No
Excessive thirst?
14.
Yes
No
Difficulty swallowing?
25.
Yes
No
Frequent urination?
15.
Yes
No
Diarrhea, constipation, blood in stools?
26.
Yes
No
Dry mouth?
16.
Yes
No
Frequent vomiting, nausea?
27.
Yes
No
Jaundice?
17.
Yes
No
Difficulty urinating, blood in urine?
28.
Yes
No
Joint pain, stiffness?
III. DO YOU HAVE OR HAVE YOU HAD:
29.
Yes
No
Heart disease?
40.
Yes
No
AIDS
30.
Yes
No
Heart attack, heart defects?
41.
Yes
No
Tumors, cancer?
31.
Yes
No
Heart murmurs?
42.
Yes
No
Arthritis, rheumatism?
32.
Yes
No
Rheumatic fever?
43.
Yes
No
Eye diseases?
33.
Yes
No
Stroke, hardening of arteries?
44.
Yes
No
Skin diseases?
34.
Yes
No
High blood pressure?
45.
Yes
No
Anemia?
35.
Yes
No
Asthma, TB, emphysema, other lung diseases?
46.
Yes
No
VD (syphilis or gonorrhea)?
36.
Yes
No
Hepatitis, other liver disease?
47.
Yes
No
Herpes?
37.
Yes
No
Stomach problems, ulcers?
48.
Yes
No
Kidney, bladder disease?
38.
Yes
No
Allergies to: drugs, foods, medications, latex?
49.
Yes
No
Thyroid, adrenal disease?
39.
Yes
No
Family history of diabetes, heart problems, tumors?
50.
Yes
No
Diabetes?
IV. DO YOU HAVE OR HAVE YOU HAD:
51.
Yes
No
Psychiatric care?
56.
Yes
No
Hospitalization?
52.
Yes
No
Radiation treatments?
57.
Yes
No
Blood transfusions?
53.
Yes
No
Chemotherapy?
58.
Yes
No
Surgeries?
54.
Yes
No
Prosthetic heart valve?
59.
Yes
No
Pacemaker?
55.
Yes
No
Artificial joint?
60.
Yes
No
Contact lenses?
V. ARE YOU TAKING:
61.
Yes
No
Recreational drugs?
63.
Yes
No
Tobacco in any form?
62.
Yes
No
Drugs, medications, over-the-counter medicines
64.
Yes
No
Alcohol?
(including Aspirin), natural remedies?
Please list:
VI. WOMEN ONLY:
65.
Yes
No
Are you or could you be pregnant or nursing?
66.
Yes
No
Taking birth control pills?
VII. ALL PATIENTS:
67.
Yes
No
Do you have or have you had any other diseases or medical problems NOT listed on this form?
If so, please explain:
To the best of my knowledge, I have answered every question completely and accurately. I will inform my dentist of any change in my health and/or
medication.
Patient’s signature:
Date:
RECALL REVIEW:
1. Patient’s signature
Date:
2. Patient’s signature
Date:
3. Patient’s signature
Date:
The Health History is created and maintained by the University of the Pacific School of Dentistry, San Francisco, California.
Support for the translation and dissemination of the Health Histories comes from MetLife Dental Care.
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