Solomon T. Woldesilassie, DDS, PC

Forms

Health History Form

American Dental Association www.ada.org

As required by law, our office adheres to written policies and procedures to protect the privacy of information about you that we create, receive or maintain. Your answers are for our records only and will be kept confidential subject to applicable laws. Please note that you will be asked some questions about your responses to this questionnaire and there may be additional questions concerning your health. This information is vital to allow us to provide appropriate care for you. This office does not use this information to discriminate.

We are located at
26224 N. Tatum Blvd.
Suite #10
Tel (480)563-4173
Fax (480)563-5019

Office Hours:
Monday - 8am to 5pm
Tuesday - 8am to 5pm
Wednesday - 8am to 5pm
THursday - 8am to 5pm
Friday - 8am to 2pm

E-mail:

Today's Date:

Name:

Home Phone:
(include area code)

Business/Cell Phone:
(include area code)

Address:

City:

State:

ZIP Code:

Occupation:

Height:

Weight:

Date of birth:

Sex:

SS# or Patient ID:

Emergency Contact:

Relationship:

Home Phone:

Cell Phone:

If you are completing this form for another person, what is your relationship to that person?

Your Name:

Relationship:

Do you have any of the following diseases or problems:
(Check DK if you don't know the answer to the question)

Active Tuberculosis
Persistent cough greater than a 3 week duration
Cough that produces blood
Been exposed to anyone with tuberculosis
If you answer yes to any of the 4 items above, please stop and return this form to the receptionist.

Dental Information
For the following questions, please check your responses to the following questions

Do your gums bleed when you brush or floss?
Are your teeth sensitive to cold, hot, sweets or pressure?
Does food or floss catch between your teeth?
Is your mouth dry?
Have you had any periodontal (gum) treatments?
Have you ever had orthodontic (braces) treatment?
Have you had any problems associated with previous dental treatment?
Is your home water supply fluoridated?
Do you drink bottled or filtered water?
If yes, how often?
Are you currently experiencing dental pain or discomfort?
What is the reason for your dental visit today?
How do you feel about your smile?
Do you have earaches or neck pains?
Do you have any clicking, popping or discomfort in the jaw?
Do you brux or grind your teeth?
Do you have sores or ulcers in your mouth?
Do you wear dentures or partials?
Do you participate in active recreational activities?
Have you ever had a serious injury to your head or mouth?
Date of your last dental exam:
Wnat was done at that time?
Date of last dental x-rays:

Medical Information
Please check your response to indicate if you have or have not any of the following diseases or problems.

Are you now under the care of a physician?
Physician Name:
Phone (include area code):
Address/City/State/Zip:
Are you in good health?
Has there been any change in your general health within the past year?
If yes, what condition is being treated?
Date of last physical exam:
Have you had a serious illness, operation or been hospitalized in the past 5 years?
If yes, what was the illness or problem?
Are you taking or have you recently taken any prescription or over the counter medicine(s)?
If so, please list all, including vitamins, natural or herbal preparations and/or diet supplements:

Check DK if you Don't Know the answer to the question

Do you wear contact lenses?
Are you taking, or have you laken, any diet drugs such as Pondimin (fenflluramine), Redux (dexphenfluramine) or phen-fen (fenflluramine-phentermine combination)?
Are you taking or scheduled to begin taking either of the medications, alendronate (Fosamax^®) or risedronate (Actonel^®) for osteoporosis or Paget's disease?
Since 2001. were you treated or are you presently scheduled to begin treatment with the intravenous bisphosphonates (Aredia^® or Zometa^®) for bone pain, hypercalcemia or skeletal complications resulting from Paget’s disease, multiple myeloma or metastatic cancer?

Do you use controlled substances (drugs)?

Do you use tobacco (smoking, snuff, chew, bidis)?

If so, how interested are you in stopping?

Do you drink alcoholic beverages?

If yes, how much akohol did you drink in the last 24 hours?

If yes, how much do you typically drink in a week?

WOMEN ONLY

Are you pregnant?

Number of weeks:

Taking birth control pills or hormonal replacement?

Nursing?

Joint Replacement. Have you had an orthopedic total jomHhip, knee, elbow, finger) replacement?

Date:

If yes, have you had any complications?

Allergies. Are you allergic to or have you had a reaction to: To all "yes" responses, specify type of reaction.
Local anesthetics
Aspirin
Penicillin or other antibiotics
Barbiturates, sedatives, or sleeping pills
Sulfa drugs
Codeine or other narcotics
Metals
Latex (rubber)
Iodine
Hay fever/seasonal
Animals
Food
Other

Please check your response to indicate if you have or have not had any of the following diseases or problems.
Heart murmur			Anemia
Mural valve prolapse			Blood transfusion
Artificial heart valves			If yes, date:
Rheumatic lever			Hemophilia
Cardiovascular disease			AIDS or HIV Infection
Angina			Arthritus
Arteriosclerosis			Autoimmune disease
Congestive heart failure			Rheumatoid Arthritis
Coronary artery disease			Systematic lupus erythematosus
Damaged heart valves			Asthma
Heart attack			Bronchitis
Low blood pressure			Emphysema
High blood pressure			Sinus trouble
Congenital heart defects			Tuberculosis
Pacemaker Rheumatic heart disease			Cancer (Chemotherapy) Radiation Treatment
Abnormal bleeding			Chest pain upon exertion
Chronic pain			Sleep disorder
Diabetes Type I or II			Mental hearth disorders
Eating disorder			Specify:
Malnutrition			Recurrent Infections
Gastrointestinal disease			Tipe of infection:
G.E. Reflux/persistent heartburn			Kidney problems
Ulcers			Night sweats
Thiroid problems			Osteoporosis
Stroke			Persistent swollen glands in neck
Glaucoma			Severe headaches/migraines
Hepatitis, jaundice or liver disease			Severe or rapid weight loss
Epilepsy			Sexually transmitted disease
Fainting spells or seizures			Neurological discorders
Excessive urination			If yes, specify:
Has a physician or previous dentist recommended that you take antibiotics prior to your dental treatment?
Name of physician or dentist making recommendation:
Phone:
Do you have any disease, condition, or problem not listed above that you think I should know about?
Please explain:

NOTE: Both Doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment.

I certify that I have read and understand the above and that the information given on this form is accurate. I understand the importance of a truthful health history and that my dentist and his/her staff wilI rely on this information for treating me I acknowledge that my questions, if any, about inquiries set forth above have been answered to my satisfaction. I will not hold my dentist, or any other member of his/her staff, responsible for any action they take or do not take because of errors or omissions that I may have made in the completion of this form.