Oral and Maxillofacial Surgery of Elkhart, Daniel Burns DDS, MD - Health History Form

*First Name

Middle Name

*Last Name

*Date of birth

*What is your height? (in.)

*What is your weight? (lbs.)

*Gender

Male Female

Health Status

good fair poor

*Have there been any changes in your general health in the past year?

Yes No

*Are you under the care of a physician?

Yes No

*Have you had any illness, operation or been hospitalized in the past five years?

Yes No

*Do you have unhealed/recurrent injuries or inflamed areas, growths or sore spots in or around your mouth?

Yes No

*Do you have a prosthetic joint/implant?

Yes No

*Have you had a heart valve replacement or vascular graft?

Yes No

*Have you ever had general anesthesia?

Yes No

*Have you, or a family member, had any unusual or serious reactions to general anesthesia?

Yes No

*Has a physician or previous dentist recommended that you take antibiotics prior to your dental treatment?

Yes No

*Rheumatic fever

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

*Cardiovascular Problems

Yes No

*Cardiac pacemaker

Yes No

*Respiratory Problems

Yes No

*Asthma

Yes No

*Hay fever/sinus problems

Yes No

*Difficult breathing/other lung trouble

Yes No

Do you smoke?

Yes No

*If so, how much a day?

*Do you use marijuana?

Yes No

*Do you use chewing tobacco?

Yes No

*Blood transfusion

Yes No

*Blood disorder such as anemia

Yes No

*Bruise easily

Yes No

*Bleeding tendency/ abnormal bleed

Yes No

*Gastrointestinal Problems

Yes No

*Urinary Tract Problems

Yes No

*Infectious mononucleosis

Yes No

*Gallbladder trouble

Yes No

*HIV/AIDS

Yes No

*Fainting spells

Yes No

*Convulsions/ epilepsy

Yes No

*Stroke

Yes No

*Thyroid trouble

Yes No

*Diabetes

Yes No

*Low blood sugar

Yes No

*Kidney trouble

Yes No

*Osteoporosis/ osteopenia

Yes No

*Osteonecrosis

Yes No

*Stomach ulcers/ acid reflux

Yes No

*Contagious or Sexually transmitted disease

Yes No

*Problems with the immune system? Possibly from medication/ surgery, etc.

Yes No

*Delay in healing

Yes No

*A tumor or growth

Yes No

*Cancer, radiation therapy or chemotherapy

Yes No

*Chronic fatigue/ night sweats

Yes No

*Are you on a diet?

Yes No

*A history of alcohol abuse

Yes No

*A history of drug use?

Yes No

*Contact lenses

Yes No

*Eye disease/ glaucoma

Yes No

*Mental health problems/ anxiety/ depression

Yes No

*Removable dental appliance

Yes No

*Pain and clicking of jaws when eating

Yes No

*Are you taking any kind of medication, drug, pills?

Yes No

*Blood thinners (Coumadin, Plavix, Aspirin, Vitamin E, Ginko biloba, Aggrenox, Pradaxa, Fish oil)

Yes No

*Are you taking, or have you ever taken bone density meds, RANKL inhibitors or bisphosphonates such as Denosumab, Fosamax, Boniva, Actonel, IV-Zometa, Aredia, Reclast, or Evista in the past 12 years?

Yes No

*Have you ever taken tranquilizers, sleeping pills, anti-depressants and/or narcotics on a regular basis. If yes, please list:

Yes No

If you are under the care of a physician for pain management, or recovering from drug addiction please select the medication you are currently taking:

*Methadone

Yes No

*Suboxone

Yes No

*Oxycodone

Yes No

*Fentanyl

Yes No

*Other

Yes No

Other Description

*Treating Doctor Name

*Local anesthetic (numbing medication)

Yes No

*Penicillin/Amoxicillin

Yes No

*Other antibiotics

Yes No

*Sulfa Drugs

Yes No

*Aspirin

Yes No

*Codeine or other narcotics

Yes No

*Latex

Yes No

*Eggs/Yolk

Yes No

*Cancer

Yes No

*Diabetes

Yes No

*Heart Disease

Yes No

*Anesthesia Problems

Yes No

*Bleeding Disorders

Yes No

*Is there any condition concerning your health that the doctor should be told about?

Yes No

Is there a possibility of pregnancy?

Yes No

Expected delivery date?

Are you nursing?

Yes No

Are you taking birth control pills?

Yes No

Date of your last period?

Have you received the HPV vaccine(gardasil)?

Yes No

Have you been vaccinated for Covid 19?

Yes No

Have you been infected with Covid 19 virus?

Yes No

Do you feel safe at home?

Yes No

History of physical or sexual abuse?

Yes No

I certify that I have read and I understand the questions above. I acknowledge that my questions, if any, about the inquiries set forth above have been answered to my satisfaction. I will not hold my doctor, or any other member of his / her staff, responsible for any errors or omissions that I have made in the completion of this form.

*Sign

*Date

By signing, I agree that this signature is the electronic representative of my personal signature for use on all documents including legally binding documents in this office - in just the same way as a pen-and-paper signature.