Dr. Tarsem L Singhal

5370 Schaefer Ave, Suite C Chino, CA, 91710 USA

909.548.6200

Health History Form

E-mail:
Today's Date:

As required by law, our office adheres to written policies and procedures to protect the privacy of information about you that we create, receive or maintain. Your answers are for our records only and will be kept confidential subject to applicable laws. Please note that you will be asked some questions about your responses to this questionnaire and there may be additional questions concerning your health. This information is vital to allow us to provide appropriate care for you. This office does not use this information to discriminate.

Name:
Home Phone:
Business/Cell Phone:
Address:
City:
State:
Zip:
Occupation:
Height:
Weight:
Date of birth::
Sex
SS# or Patient ID:
Emergency Contact:
Relationship:
Home Phone:
Cell Phone:
If you are completing this form for another person, what is your relationship to that person?
Your Name
Relationship
Do you have any of the following diseases or problems: (Check DK if you Don't Know the answer to the question)
Active Tuberculos
Persistent cough greater than a 3 week duration
Active Tuberculos
Been exposed to anyone with tuberculosis

If you answer yes to any of the 4 items above, please stop filling this form.


Dental Information
Do your gums bleed when you brush or floss?
Are your teeth sensitive to cold, hot, sweets or pressure?
Does food or floss catch between your teeth?
Is your mouth dry?
Have you had any periodontal (gum) treatments?
Have you ever had orthodontic (braces) treatment?
Have you had any problems associated with previous dental treatment?
Is your home water supply fluoridated?
Do you drink bottled or filtered water?
If yes, how often?
Are you currently experiencing dental pain or discomfort?
Do you have earaches or neck pains?
Do you have any clicking, popping or discomfort in the jaw?
Do you brux or grind your teeth?
Do you brux or grind your teeth?
Do you wear dentures or partials?
Do you participate in active recreational activities?
Have you ever had a serious injury to your head or mouth?
Date of your last dental exam:
What was done at that time?
Date of last dental x-rays:
What is the reason for your dental visit today?
How do you feel about your smile?
Medical Information

Please select your response to indicate if you have or have not had any of the following diseases or problems.

Are you now under the care of a physician?
Physician Name:
Phone:
Address/City/State/Zip:
Are you in good health?
Has there been any change in your general health within the past year?
If yes, what condition is being treated?
Date of last physical exam:
Have you had a serious illness, operation or been hospitalized in the past 5 years?
If yes, what was the illness or problem?
Are you taking or have you recently taken any prescription or over the counter medicine(s)?
If so, please list all, including vitamins, natural or herbal preparations and/or diet supplements
Do you wear contact lenses?
Joint Replacement. Have you had an orthopedic total joint (hip, knee, elbow, finger) replacement?
Date:
If yes, have you had any complications?
Are you taking or scheduled to begin taking either of the medications, alendronate (Fosamax®) or risedronate (Actonel®) for osteoporosis or Paget’s disease?
Since 2001, were you treated or are you presently scheduled to begin treatment with the intravenous bisphosphonates (Aredia® or Zometa®) for bone pain, hypercalcemia or skeletal complications resulting from Paget’s disease, multiple myeloma or metastatic cancer?
Date Treatment began:
Do you use controlled substances (drugs)?
Do you use tobacco (smoking, snuff, chew, bidis)?
If so, how interested are you in stopping?
Do you drink alcoholic beverages?
If yes, how much alcohol did you drink in the last 24 hours?
If yes, how much do you typically drink in a week?

WOMEN ONLY

Are you Pregnant?
Number of weeks:
Taking birth control pills or hormonal replacement?
Nursing?

Allergies

Are you allergic to or have you had a reaction to:

To all yes responses, specify type of reaction.

Local anesthetics
Aspirin
Penicillin or other antibiotics
Barbiturates, sedatives, or sleeping pills
Sulfa drugs
Codeine or other narcotics
Metals
Latex (rubber)
Iodine
Hay fever/seasonal
Animals
Food
Other
Please select your response to indicate if you have or have not had any of the following diseases or problems.
Artificial (prosthetic) heart valve
Previous infective endocarditis
Damaged valves in transplanted heart
Congenital heart disease (CHD)
Unrepaired, cyanotic CHD
Repaired (completely) in last 6 months
Repaired CHD with residual defects

Except for the conditions listed above, antibiotic prophylaxis is no longer recommended for any other form of CHD.

Cardiovascular disease
Angina
Arteriosclerosis
Congestive heart failure
Damaged heart valves
Heart attack
Heart murmur
Low blood pressure
High blood pressure
Other congenital heart defects
Mitral valve prolapse
Pacemaker
Rheumatic fever
Rheumatic heart disease
Abnormal bleeding
Anemia
Blood transfusion
If yes, date
Hemophilia
AIDS or HIV infection
Arthritis
Autoimmune disease
Rheumatoid arthritis
Systemic lupus erythematosus
Asthma
Bronchitis
Emphysema
Sinus trouble
Tuberculosis
Cancer/Chemotherapy/ Radiation Treatment
Chest pain upon exertion
Chronic pain
Diabetes Type I or II
Eating disorder
Malnutrition
Gastrointestinal disease
G.E. Reflux/persistent heartburn
Ulcers
Thyroid problems
Stroke
Glaucoma
Hepatitis, jaundice or liver disease
Epilepsy
Fainting spells or seizures
Neurological disorders
If yes, specify
Sleep disorder
Mental health disorders
Specify
Recurrent Infections
Type of infection
Kidney problems
Night sweats
Osteoporosis
Persistent swollen glands in neck
Severe headaches/ migraines
Severe or rapid weight loss
Sexually transmitted disease
Excessive urination
Has a physician or previous dentist recommended that you take antibiotics prior to your dental treatment?
Name of physician or dentist making recommendation
Phone:
Do you have any disease, condition, or problem not listed above that you think I should know about?
Please explain

NOTE: Both Doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment.

I certify that I have read and understand the above and that the information given on this form is accurate. I understand the importance of a truthful health history and that my dentist and his/her staff will rely on this information for treating me. I acknowledge that my questions, if any, about inquiries set forth above have been answered to my satisfaction. I will not hold my dentist, or any other member of his/her staff, responsible for any action they take or do not take because of errors or omissions that I may have made in the completion of this form.

Signature of Patient/Legal Guardian:

Use your mouse cursor or the tip of your finger to sign below

Date:

FOR COMPLETION BY DENTIST

Comments:

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