Pismobeachdentistry.net

CHRISTOPHER STELLPFLUG, D.D.S.
CONFIDENTIAL HEALTH HISTORY

Patient Name: ______________________________________Date of Birth:_________________________________

I. CIRCLE APPROPRIATE ANSWER (Leave blank if you do not understand the question)
1. Yes / No
Is your general health good? If NO, explain:____________________________________________________________________ Has there been a change in your health within the last year? If YES, explain: __________________________________________________________________ Have you gone to the hospital or emergency room or had a serious illness in the last three years? If YES, explain:___________________________________________________________________ Are you being treated by a physician now? If YES, explain: __________________________________________________________________ Date of last medical exam:____________________ Reason for exam: _______________________ Have you had problems with prior dental treatment? If YES, explain: Date of last dental exam:______________________ Name of last treating dentist:_______________ Are you in pain now? If YES, explain: ___________________________________________________________________ II. HAVE YOU EXPERIENCED ANY OF THE FOLLOWING? (Please circle Yes or No for each)
Yes / No Chest pain (angina)

III. HAVE YOU HAD OR DO YOU HAVE ANY OF THE FOLLOWING? (Please circle Yes or No for each)
Yes / No Heart disease
Yes / No Family history of heart disease Yes / No Surgeries Yes / No Stomach problems or ulcers Yes / No Family history of diabetes Yes / No Hepatitis Yes / No Heart defects Yes / No Emphysema or lung disease Yes / No Liver disease Yes / No Kidney or bladder disease Yes / No Eye disease
IV. ARE YOU ALLERGIC TO OR HAVE YOU HAD A REACTION TO ANY OF THE FOLLOWING?
(Please circle Yes or No for each)
Yes / No Aspirin
(Novocain or Xylocaine)
Others:______________________________________________________________________________________________
V. ARE YOU TAKING OR HAVE YOU TAKEN ANY OF THE FOLLOWING IN THE LAST THREE MONTHS?
(Please circle Yes or No for each)
Yes / No Recreational drugs
Yes / No Over-the-counter medicines Yes / No Alcohol Yes / No Bisphosphonate (Fosamax) Yes / No Aspirin Please list:____________________________________________________________________________________________

VI. WOMEN ONLY (Please circle Yes or No for each)
Yes / No Are you or could you be pregnant? If YES, what month?____________________________________________
Yes / No Are you nursing?
Yes / No Are you taking birth control pills?

VII. ALL PATIENTS (Please circle Yes or No for each)
Yes / No Do you have or have you had any other diseases or medical problems NOT listed on this form?
If YES, please explain: ___________________________________________________________________________________
Yes / No Have you ever been pre-medicated for dental treatment? If YES, why:_____________________________________
Yes / No Have you ever taken Fen-Phen? If YES, when: _______________________________________________________
Yes / No Is there any issue or condition that you would like to discuss with the dentist in private?
The practice of dentistry involves treating the whole person. If the dentist determines that there may be a potentially medically-
compromised situation, medical consultation may be needed prior to commencement of dental treatment.
I authorize the dentist to contact my physician.

Patient’s Signature: _________________________________________________ Date:_______________________________
Physician’s Name: _________________________________________________Phone Number: ________________________

I certify that I have read and understand this form. To the best of my knowledge, I have answered every question
completelyand accurately. I will inform my dentist of any change in my health and/or medication. Further, I will not
hold my dentist, or any other member of his/her staff, responsible for any errors or omissions that I may have made in
the completion of this form.
________________________________________________________
__________________________
Signature of Patient (Parent or Guardian)

Source: http://www.pismobeachdentistry.net/docs/health-history.pdf