Dr. Sellas & Team – Patient Medical/Dental Health History

Patient Information

Patient Name:
Patient DOB:
Date:

Medical History – Conditions

Have you had or do you currently have any of the following?

For surgery today: Ate/drank in last 8 hours? Yes No
Who is driving you home?

Medications

Blood Thinners? Yes No
Diet Pills? Yes No
Herbal Supplements / Remedies? Yes No
Bone Density Medications? Yes No
Tranquilizers / Sleeping Pills / Narcotics? Yes No
If yes, list:

Allergies

Local Anesthetics? Yes No
Penicillin? Yes No
Other Antibiotics? Yes No
Sulfa Drugs? Yes No
Tranquilizers (Valium, etc.)? Yes No
Aspirin? Yes No
Codeine / Narcotics? Yes No
Other Medications? Yes No
Latex? Yes No
Soy? Yes No
Eggs / Yolk? Yes No
Sulfites? Yes No
Other allergies:

Women Only

Possibility of pregnancy? Yes No
Expected delivery date:
Nursing? Yes No
Taking birth control pills? Yes No

General Health

Reason for today’s visit:
Height:
Weight:
In good health? Yes No
Changes in health in past year? Yes No
Under care of physician? Yes No
Illness/operation in past 5 years? Yes No
Physician name:
Physician phone:
Last visit:
If yes, describe:

Health Conditions Checklist

Please answer Yes/No

Diabetes (Insulin / Pill): Yes No
Damaged Heart Valves / Mitral Valve Prolapse: Yes No
Heart Murmur: Yes No
High Blood Pressure: Yes No
Low Blood Pressure: Yes No
Chest Pain / Angina: Yes No
Heart Attack(s): Yes No
Irregular Heart Beat: Yes No
Cardiac Pacemaker: Yes No
Heart Surgery: Yes No
Bronchitis / Chronic Cough: Yes No
Asthma: Yes No
Hay Fever / Sinus Problems: Yes No
Hepatitis A: Yes No
Smoke? Yes No
Chewing Tobacco? Yes No
Blood Transfusion: Yes No
Anemia / Blood Disorder: