Shek Health Questionnaire

Health Questionnaire
These questions are for your benefit and assure that treatment will take into consideration your past and present health status. Some questions may seem unrelated to your dental condition, but they are all associated with proper oral health care. Please answer each question. Check the appropriate box Yes or No where applicable.
Medical History
Patient's Name*

First NameLast Name
Are you in good health?

YesNo
Date of last physical examination
Are you now under the care of a physician?

YesNo
If yes, what is the condition being treated?
Have you ever had any serious illness or operation?

YesNo
If so, what illness or operation?
Have you ever been hospitalized?

YesNo
If so, what was the problem?
Are you taking any ...

MedicationsDrugsHerbs
If so, what?
What dosage?
Are you using any recreational drugs (marijuana, cocaine, etc.)?

YesNo
If so, what?
Have you ever been pre-medicated with antibiotics for your dental treatment?

YesNo
Are you sensitive or allergic to any drugs or materials?

PenicillinTetracyclineSulfa drugsAspirinCodeineOption 6Other
Do you have or have you had any of the following: (Please check if applicable)
Do you have any disease, condition or problem not listed that you think we should know about?

YesNo
If so, what?
Do you wear a cardiac pacemaker, or have you had heart surgery?

YesNo
Do you smoke? If yes, how much?

CigarettesCigarsPacks per day
Have you ever taken the drugs ...

Fen-PhenReduxFosamax (Bisphophonate)ZometaActonelBonivaArediaDiet drugs
(Women) Are you pregnant?

YesNo
If so, how many months?
(Women) Do you have any problems associated with your menstrual period?

YesNo
(Women) Do you take any birth control medication or hormones?

YesNo
Dental History
Have you ever had a local anesthetic (Novocaine, etc.)?

YesNo
Have you ever had an unfavorable reaction from a local anesthetic?

YesNo
Have you ever had any serious trouble associated with any previous dental treatment?

YesNo
If so, explain?
How long since your last full mouth X-Rays?

WeeksMonthsYears
How long since your last dental treatment

WeeksMonthsYears
Does dental treatment make you nervous?

NoSlightlyModeratelyExtremely
Would you desire to be pre-sedated?

YesNo
I hereby acknowledge I have received a copy of this practice's NOTICE OF PRIVACY PRACTICES. I further understand that the practice will offer me updates to this NOTICE OF PRIVACY PRACTICES should it be amended, modified, or changed in any way.Patient refused/was unable to signI have received a copy of the Dental Materials Fact Sheet as required by law.
To the best of my knowledge, all of the preceding answers are true and correct. If I ever have any change in my health or if my medications change, I will, without fail, inform the doctor at my next appointment.
Signature
Date

MonthDayYear
Update - Since your last visit (if applicable)
Have you seen a medical doctor?

YesNo
Have you had a change in your medication?

YesNo
Have you had a change in your medical condition or had surgery?

YesNo
Consent for Treatment
I hereby grant authority to the dentist(s) in charge of the care of the patient whose name appears on this Health Histiry form, to administer such anesthetics, analgesics, sedatives, nitrous oxide sedation and intravenous sedation; and to perform such operations as may be deemed necessary or advisable in the diagnosis and treatment of this patient. I have been informed of all possible complications of the procedures, anesthetics and/or drugs.

All services are rendered and accepted under the terms and conditions printed on the reverse hereof: Authorization must be signed by the patient, or by the nearest relative in the case of a minor when the patient is physically or mentally incompetent.
Signed
Date

MonthDayYear
Relationship to patient
Should be Empty:

Health Questionnaire

Dental History

Update - Since your last visit (if applicable)

Consent for Treatment