DENTAL HEALTH HISTORY QUESTIONNAIRE Name DENTAL HEALTH HISTORY QUESTIONNAIRE All answers contained in this questionnaire are strictly confidential and will become part of your dental record. First Name: * Last Name: * Date of Birth: * DO YOU HAVE A HISTORY OF ANY OF THE FOLLOWING AIDS/HIV * YES NO Stents OR Pacemaker OR Artificial Valves in Heart * YES NO Arthritis OR Cortisone Treatments * YES NO Glaucoma * YES NO Back Problems * YES NO Seizures OR Epilepsy * YES NO Chemical Dependency * YES NO Lung Disease * YES NO Headaches * YES NO Asthma OR COPD OR Shortness of Breath * YES NO Excessive Bleeding * YES NO Tuberculosis * YES NO Fainting or Dizziness * YES NO Bloody OR Persistent Cough * YES NO Diabetes * YES NO High Blood Pressure * YES NO Anemia * YES NO Liver Disease * YES NO Kidney Disease * YES NO Thyroid Disease * YES NO Sexually Transmitted Disease * YES NO Psychological Disorder or Treatment * YES NO Heart Disease OR Congenital Heart Defect * YES NO Aneurism OR Heart Attack OR Stroke * YES NO Cancer * YES NO Cancer If yes, list type of cancer and treatment received: Artificial Joint If Yes, list of joint(s) involved: * YES NO Joint(s) involved: WOMEN Are you pregnant? YES NO Are you nursing? YES NO List your prescribed drugs and over-the-the-counter drugs, such as vitamins and inhalers. List Drugs List any allergies to medications. List Allergies List any other medical problems/conditions that were NOT mentioned above: List Other Do you use tobacco or an electronic cigarette? * YES NO Total Years Total years Year Quit Year Quit Number Year Quit Cigs a day Cigarettes Packs a day Chew Chew Chew a day Pipe Pipe Pipe a day Cigars Cigars Cigars a day Patient/Parent/Guardian Signature: (Type) * Preferred Pharmacy: Date * Dentist Signature: ASA Number: MRM: THANK YOU FOR CHOOSING ACCELHEALTH!