Dr. Singh's Dental Studio - Health History, Advanced Dental Care, Esthetic Dentist, Dental Implant Clinic

ABOUT US
Mission Statement Comprehensive Consultation Infection Control
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Information for New Patients FAQ's
Forms
Getting to know you Health History Insurance Information

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Office Hours

Monday - Saturday

Flexible hours, By Appointments Only.

Health History

Name(last)		Name(First)
Birth Date		Physician name
Phone		Date last Visit
Address		City
state		zip
Email

Major dental problem or reason for coming today

Have you had an unexplained gain or loss of weight (past 6 months)?		Yes No
Do you smoke or use tobacco? If Yes. How much?		Yes No
Do you drink alcoholic beverages? If Yes. How much?		Yes No

Have you ever been treated for cancer?		Yes No
Have you ever had radiation treatment?		Yes No
Do you have a poor appetite?		Yes No
Do you sleep poorly or use medications to sleep?		Yes No
Do you feel that you are currently more tired than usual?		Yes No
Do you have many body aches and pains?		Yes No
Do you have night sweats or recurring fever?		Yes No
Have you ever used intravenous drugs?		Yes No
Have you used cocaine or "crack" within the past 6 months?		Yes No
Do you actively engage in high risk behavior for infectious diseases (e.g. AIDS, Hepatitis)?		Yes No
Please describe your general health (Select One)		Good Fair Under Doctor's Care

Head And Neck

Recurrent headaches	Yes No
Glaucoma I eye disease	Yes No
Recurrent earaches/hearing problems	Yes No
Chronic sinusitis/post-nasal	Yes No
Recent difficulty swallowing	Yes No
Persistent sore throat and hoarseness	Yes No
Swollen neck glands	Yes No
Recurrent neck ache or neck pain	Yes No
Injury to head, neck, jaw, teeth	Yes No
Dental

Chronic face pain/ jaw pain	Yes No
Clicking/ popping jaw	Yes No
Difficulty opening or closing jaw	Yes No
Unable to chew food well	Yes No
Blisters / sores on lips or mouth	Yes No
Unpleasant taste	Yes No
Burning tongue/lips	Yes No
Uncomfortable bite	Yes No
Swelling/lumps in mouth	Yes No
Bleeding or infected gums	Yes No
Loose teeth	Yes No
Pain when chewing or opening mouth	Yes No
Catch food between teeth	Yes No
Recent toothache/sensitivity	Yes No
Clenching/grinding	Yes No
Your bite adjusted	Yes No
Bite appliance	Yes No
Gum treatment and surgery	Yes No
Orthodontic treatment (braces)	Yes No
Neuromuscular System

Fainting spells or loss of consciousness	Yes No
Seizures	Yes No
Numbness, tingling, or paralysis	Yes No
Muscle weaknesses/ multiple sclerosis	Yes No
Recurrent backache	Yes No
Problem I walking, balance, dizziness	Yes No
Persistent stiffness or painful joints	Yes No
Artificial bone or joint implants	Yes No
Recent unusual headaches	Yes No
Respiratory

Breathing problems	Yes No
Asthma or Emphysema	Yes No
Tuberculosis or a persistent cough	Yes No
Coughed up blood	Yes No
Pneumonia	Yes No
Cardiovascular

High blood pressure	Yes No
Awaken with breathing difficulty	Yes No
Difficulty breathing when lying	Yes No
Swollen ankles	Yes No
Irregular or rapid heart beats	Yes No
Chest pain due to physical exertion	Yes No
Chest pain when upset	Yes No
Rheumatic heart disease or fever	Yes No
Congenital heart disease/ heart murmur	Yes No
Prolapsed heart valve	Yes No
Cardiac or vascular	Yes No
Heart attack and/or angina	Yes No
Other heart problem	Yes No
Stroke	Yes No
Do you have or have you ever had:

Persistent diarrhea/odd colored stools	Yes No
Colitis or ulcers	Yes No
Unexplained vomiting/ frequent nausea	Yes No
Alcoholic liver disease	Yes No
Hepatitis or other liver disease	Yes No
Jaundice (yellow skin or eyes)	Yes No
Awaken more than twice a night to urinate	Yes No
Kidney disease/renal dialysis	Yes No
A kidney transplant	Yes No
Any urinary infection	Yes No
Syphilis	Yes No
Gonorrhea	Yes No
Any other sexually transmitted disease	Yes No

Have you been allergic to or had a bad reaction to Allergies

Penicillin	Yes No
Sulfa drugs	Yes No
Dental anesthetics	Yes No
Metals (rings/earrings)	Yes No
Other (specify)	Yes No
Bruise easily/bleed excessively after a cut	Yes No
A blood transfusion	Yes No
Anemia or denied permission to give blood	Yes No
Leukemia (cancer of the blood)	Yes No
Diabetes or frequently thirsty	Yes No
Thyroid or adrenal gland disease	Yes No
AIDS or ARC (AIDS related Complex)	Yes No
Positive blood test for HIV antibodies	Yes No
Skin blotches or rash	Yes No
Rheumatoid arthritis	Yes No
Chronic itching	Yes No
Women Only

Do you menstruate regularly?	Yes No
Do you flow heavily?	Yes No
Are you now pregnant?	Yes No
If so, please give due date
Are you in menopause stage?	Yes No
Are you taking hormones?	Yes No

Has anyone in your family (grandparent, parent, sibling, and child ever had:

Family History

Bleeding disorder	Yes No
Heart diseases	Yes No
Mental/ emotional disorders	Yes No
Any genetic diseased/illness(please specify)
Cancer	Yes No
Tuberculosis	Yes No
Diabetes	Yes No
Behavioral

Are you available and able to sit for three hours appointment?	Yes No
Are there some aspects of the appearance of your teeth and jaw that need to have changed?	Yes No
Do you of the feel depressed or moody?	Yes No
Do you of the fell anxious or nervous?	Yes No
Have you ever had psychiatric or physical counseling?	Yes No
Did you ever avoid a dental appointment because you were frightened?	Yes No
Do you ever feel uncomfortable asking question of doctors?	Yes No

List of prescription and non prescription drugs (including aspirin) taken within that past 6 months:

Name & DosageName & DosageName & Dosage

Please list all hospitalizations and emergency room visits (include dates and reasons):
1. 2.
3. 4.

Have you ever been dissatisfied with your previous dental treatment?	Yes No
If yes, please explain

I have read and understood the questionnaire and have answered all questions truthfully to the best of my ability. If ever my health or medication changes, I will inform my dentist at my next appointment.

Patient__________ Date Guardian__________Date Dentist__________Date

Contact

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Dental Humor

Complementary initial 30 minutes Consultation (Consultation Only) with the Dentist for Dental Implants & Cosmetics.