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Northgate Dental Health


Health History is very important for most types of dental treatment, but especially important if you are considering any form of Sedation. Medications and certain medical conditions can affect treatment outcomes. Please be as thorough as possible.

  • Date and purpose of last medical exam*
  • Have you been hospitalized in the past 5 years?* Yes No
  • If yes, please state reason
  • Are you currently receiving care? Yes No
  • Please list name and phone of all physicians who are currently providing care. State NONE if that applies.
  • For the following questions choose yes or no. Your answers are for our records only and will be confidential. Please note that during your initial visit you will be asked some questions about your response. Our team may ask additional questions concerning your health
  • Anemia or Blood Disorder Yes No
  • Arthritis, Rheumatism or other inflammatory disease Yes No
  • Diabetes Yes No
  • Epilepsy Yes No
  • Fainting or Dizzy spells Yes No
  • Abnormal Heart or Previous Bacterial Endocarditis Yes No
  • Heart Murmur (mitral valve prolapse) Yes No
  • Heart (Surgery, Disease, Attack) Yes No
  • Heart Valve (artificial) or Heart Transplant Yes No
  • Heart Stent Yes No
  • If yes, when placed
  • Joint Replacement Yes No
  • If yes, when
  • Rheumatic Fever Yes No
  • Hepatitis Yes No
  • Emphysema or other Respiratory Illnesses Yes No
  • Kidney Disease Yes No
  • Venereal Disease Yes No
  • HIV Infection/AIDS or ARC Yes No
  • Snoring/Sleep Apnea Yes No
  • Bruxism (grinding or clenching teeth during day/night) Yes No
  • Psychosis Yes No
  • Glaucoma Yes No
  • Asthma Yes No
  • Abnormal bleeding when cut Yes No
  • Are you taking blood thinners? (including aspirin or coumidin) Yes No
  • Sore or enlarged lymph nodes Yes No
  • Previous biopsies Yes No
  • Radiation or Chemotherapy Treatment Yes No
  • Liver Disease (including Jaundice) Yes No
  • Slow-Healing Mouth Sores Yes No
  • Do you have headaches? Yes No
  • Present or previous drug addiction? Yes No
  • Unintentional weight Loss/Gain Yes No
  • Other Conditions
  • Recurrent Illnesses
  • Items with* are required. Are you taking any of the following?
  • Have you been told you should Pre-Medicate before any dental treatment? Yes No
  • Do you use antacids? Yes No
  • Dilantin or Tegretol? Yes No
  • Barbituarates (any) Yes No
  • St John's Wort or Kava-Kava? Yes No
  • Tagamet (cimetidine) or Prilosec (omeprazole)? Yes No
  • Cardizem (diltiazem) or Calan, Isoptin (Verapamil)? Yes No
  • Serzone (nefazodone) Yes No
  • Diflucan (fluconazole) or Sporonox (itraconazole) Yes No
  • Biaxin (clarithromycin)? Yes No
  • Have you ever been treated with Biophosphate drugs (Fosomax, Aredia, Zometa, Actonel, Boniva)? Yes No
  • If yes, when did treatment begin?
  • When did treatment stop?
  • Have you ever taken fen-phen for weight loss? Yes No
  • Do you consume grapefruit juice, grapefruits or grapefruit extract? Yes No
  • Please list ALL medications you are taking

See also:

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