Dr Paul Leatham DMD
899 N Wilmot Suite E4
Leathamdental.com
520-745-9723
Health History
Patient:________________________________
Birth Date______________________________
Primary Care Physician________________________________
Physician’s Phone #:__________________________________
List All Medications and supplements you are currently taking: _________________________________________________________
________________________________________________________________________If more than 5 please provide separate list
Are you taking any blood thinners such as Plavix, or Warfarin? Yes/ No
Are you taking or have you ever taken a Bisphosphonate such as Fosamax? Yes / No
Are you allergic to any of the following?
Local Anesthetics
Y N Penicillin
Y N Codeine
Y N Aspirin
Y N
Latex
Y N Acrylics
Y N Metals
Y N Sulfa
Y N
Please list any other allergies:___________________________________________________________________________________
For Women Only:
Are you pregnant?
Are you trying to get pregnant?
Y N If yes how many weeks pregnant?
Y N Are you taking oral contraceptives
1-12 1st tri, 13-28 2nd tri, 28-40 3rd tri
Y N Have you gone through menopause
Y N
Do you have any of the following Conditions?
Asthma
Y N Artificial Heart Valve
Y N Artificial Bones/Joints
Y N Thyroid Disease
Y N
COPD
Y N Bruise Easily
Y N Kidney Disease
Y N Parathyroid Disease
Y N
Difficulty Breathing
Y N Sickle Cell Disease
Y N Jaundice
Y N Gastrointestinal Disease Y N
Lung Disease
Y N Alcohol/Drug Abuse
Y N Liver Disease
Y N Acid Reflux
Y N
Pneumonia
Y N Frequent Headaches
Y N Hepatitis A, B or C
Y N Diabetes
Y N
Hemophilia
Y N Epilepsy or Seizures
Y N Herpes
Y N Recent Weight Loss
Y N
Excessive Bleeding
Y N Fainting Spells
Y N Venereal Disease
Y N Fever Blisters
Y N
Anemia
Y N Cancer/Chemotherapy Y N HIV or AIDS
Y N Sinus Troubles
Y N
Pacemaker
Y N Radiation Treatment
Y N Tuberculosis
Y N Glaucoma
Y N
Angina/Chest Pain
Y N Leukemia
Y N Rheumatic Fever
Y N Cosmetic Surgery
Y N
High Blood Pressure
Y N Arthritis
Y N Cold Sores
Y N Smoking/Tobacco Use
Y N
Low Blood Pressure
Y N Bone Disorder
Y N Psychiatric Care
Y N Anaphylaxis
Y N
Heart Attack or Surgery
Y N If yes Date:
Stroke
Y N If yes Date:
Other:_______________________________________________________________________________________________________
Have you had any major hospitalizations? Yes No If yes please list_______________________________________________________
Have you had any major injuries? Yes No If yes please list _____________________________________________________________
Sleep: - Do you snore? Y / N - Do you wake up taking deep breaths? Y / N – Do your regularly feel tired during the day? Y / N
- Do you wake up multiple times at night? Y / N - Has anyone ever nudged you at night because of snoring or breathing? Y / N
- Are you able to sleep on your back? Y / N – Have you ever had CPAP therapy? Y / N - If Yes were you able to tolerate it? Y / N
To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be
dangerous to my (or patient’s) health. It is my responsibility to inform the dental office of any changes in medical status.
SIGNATURE OF PATIENT,PARENT or GUARDIAN:_______________________________________________Date:_________________
Doctor’s notes: