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Patient Record
Health History
I. Please check the appropriate boxes below. Leave the boxes blank if you do not understand the question:
Is your general health good?
Has there been a change in your health within the last year?

Have you ever beeen hospitalized or had a serious illness in the last three years?


Are you being treated by a physician now?

Have you had problems with prior dental treatments?
Are you in pain now?
II. Have You Experienced?
Chest pain (angina)? Dizziness?
Swollen ankles? Shortness of breath?
Recent weight loss, fever, night sweats? Fainting spells?
Persistent cough, coughing up blood? Seizures?
Excessive thirst? Difficulty swallowing?
Jaundice? Difficulty urinating, blood in urine?
III. Do You Have or have you had?
Heart disease? AIDS or ARC?
Heart attack, heart defect? Tumors, cancer?
Heart murmurs? Arthritis, rheumatism?
Heart surgery? Eye disease?
Heart valve disorder? Pacemaker?
Heart valve replacement? Anemia?
Rheumatic heart disease? VD (syphilis or gonorrhea)?
High blood pressure? Herpes?
Stroke, hardening of arteries? Kidney, bladder disease?
Hepatitis, other liver disease? Thyroid, adrenal disease?
Radiation treatments? Diabetes?
Family history of diabetes, heart problems, tumors?

Allergies to drugs food, medications?

Chemotherapy? Artificial joint?
IV. Are You Taking?

Drugs, medicines, (including Aspirin)?

Please list:

Are you or could you be pregant or nursing? Taking birth control pills?
VI. All Patients:

Do you have or have you had other diseases or medical problems NOT listed on this form?

I hereby consent to the examination, x-rays, use of anesthetics, analgesia, antibiotics and other medication required, and the performace of all dental treatment the doctor may consider necessary for good health and to the best of my knowledge, I have answered every question completely and accurately. I will inform my dentist of any change in my nealth and/or medication.

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    Wellness Dentistry    
      11777 Bernardo Plaza Ct., Suite 106
      San Diego, CA 92128    
    Phone: (858) 485-6199
    Wellness Dentistry    
      2452 Fenton Street, Suite 103
      Chula Vista, CA 91914    
    Phone: (619) 216-3333
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