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Patient Forms - Health History Form

Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive.

If you would prefer to print out the form and bring it with you, click on the link below. Otherwise an online form has been provided below. Thank you for answering the following questions.

Health History Form (pdf)

Patient's Name:


Birth Date:


Although dental personnel primarily treat the area in and around the mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions.

Are you currently under a physician's care for a medical condition (besides routine/annual exams)?
 Yes  No   If yes:


Have you been diagnosed with any special needs condition(s) or disorders(s)? If so, what type?
 Yes  No   If yes:


Have you ever been hospitalized or had a major operation?
 Yes  No   If yes:


Have you ever had a serious head or neck injury?
 Yes  No   If yes:


Are you taking any medications, pills, or drugs?
 Yes  No   If yes:


Do you take, or have you taken, Phen-Fen or Redux?
 Yes  No   If yes:


Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates?
 Yes  No   If yes:


Are you on a special diet?
 Yes  No   If yes:


Do you smoke or use chewing tobacco?
 Yes  No   If yes:


Do you use controlled substances?
 Yes  No   If yes:


Women: Are you
 Pregnant?   Trying to get pregnant?   Nursing?   Taking oral contraceptives?
Are you allergic to any of the following?
 Aspirin   Penicillin   Codeine   Acrylic   Metal   Latex   Local Anesthetics   Clindamycin   Amoxicillin   Other
Do you have, or have you had, any of the following?
Acid Reflux Yes No
ADD/ADHD Yes No
AIDS/HIV Positive Yes No
Alzheimer's Disease Yes No
Anaphylaxis Yes No
Anemia Yes No
Angina Yes No
Anxiety Yes No
Arthritis/Gout Yes No
Artificial Heart Valve Yes No
Artificial Joint Yes No
Asperger Syndrome Yes No
Asthma Yes No
Autism Spectrum Disorder Yes No
Blood Disease Yes No
Blood Transfusion Yes No
Breathing Problems Yes No
Bruise Easily Yes No
Cancer Yes No
Celiac Disease Yes No
Chemotherapy Yes No
Chest Pains Yes No
Cold Sores/Fever Blisters Yes No
Congenital Heart Disorder Yes No
Convulsions Yes No
Cortisone Medicine Yes No
Crohn's Disease Yes No
Diabetes Yes No
Drug Addiction Yes No
Easily Winded Yes No
Emphysema Yes No
Epilepsy or Seizures Yes No
Excessive Bleeding Yes No
Excessive Thirst Yes No
Fainting Spells/Dizziness Yes No
Frequent Cough Yes No
Frequent Diarrhea Yes No
Frequent Headaches Yes No
Glaucoma Yes No
Hay Fever Yes No
Heart Attack/Failure Yes No
Heart Murmur Yes No
Heart Pacemaker Yes No
Heart Trouble/Disease Yes No
Hemophilia Yes No
Hepatitis A Yes No
Hepatitis B or C Yes No
Herpes Yes No
High Blood Pressure Yes No
High Cholesterol Yes No
Hives or Rash Yes No
Hypoglycemia Yes No
Irregular Heartbeat Yes No
Kidney Problems Yes No
Leukemia Yes No
Liver Disease Yes No
Low Blood Pressure Yes No
Lung Disease Yes No
Lupus Yes No
Mitral Valve Prolapse Yes No
Osteoporosis Yes No
Pain in Jaw Joints Yes No
Parathyroid Disease Yes No
Psychiatric Care Yes No
Radiation Treatments Yes No
Recent Weight Loss Yes No
Renal Dialysis Yes No
Rheumatic Fever Yes No
Rheumatism Yes No
Scarlet Fever Yes No
Shingles Yes No
Sickle Cell Disease Yes No
Sinus Trouble Yes No
Spina Bifida Yes No
Stomach/Intestinal Disease Yes No
Stroke Yes No
Swelling of Limbs Yes No
Thyroid Disease Yes No
Tonsillitis Yes No
Tuberculosis Yes No
Tumors or Growths Yes No
Ulcers Yes No
Yellow Jaundice Yes No
  

**If you have an artificial joint, do you require pre-medication for your dental appointments?
 Yes  No   If yes, please explain:


Have you ever had any serious illness not listed above?
 Yes  No   If yes, please explain:


Comments:

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in medical status.

By typing your name in the space provided below, this serves as your digital signature which affirms the information you provided is correct.

Signature of Patient, Parent, or Guardian (Please type your full name): Signature is Required.

Date:



14221 Metcalf Ave
Suite 100
Overland Park, Kansas 66223

Phone: 913.851.5900
Fax: 913.851.5912

Email: info@lenzdds.com


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