HEALTH QUESTIONNAIRE

For optimal safety, it is necessary that you answer the following questions.
This information will be held in utmost confidence.

Patient's Name DOB: Date:



HAVE YOU EVER HAD OR HAVE YOU NOW: (Answer all questions by selecting Yes (Y) or No (N)
Recent illness (within one year) | Cough, cold or flu (within two weeks) | Nose obstruction |
Shortness of breath | Epilepsy or Seizure | Fainting or Dizziness |
Depression | Psychiatric Treatment | Stroke |
Glaucoma | Cold sores (Herpes) | Persistent cough |
Emphysema | Tuberculosis / PPD Positive | Asthma |
Bronchitis | Sinus problems | Anemia |
Sickle Cell Disease | Hemophilia (Bleeding Disorder) | Bruise or bleed easily |
Heart problems or chest pains | Do your ankles swell? | Heart Attack |
Irregular heart beat | Hypertension (High blood pressure) | Rheumatic fever |
Heart murmur | Mitral valve prolapse | Congenital heart lesions |
Heart surgery | Prosthetic heart valve(s) | Pacemaker |
Blood transfusion(s) | Liver disease (Cirrhosis) | Yellow jaundice |
Hepatitis - type: | Snoring / Sleep Apnea | Stomach Ulcers or Colitis |
Kidney problems | Blood vessel grafts | Sexually Transmitted disease |
Diabetes | Thyroid disease (Goiter) | AIDS / HIV positive |
Arthritis | Painful joints (incl jaw) | Prosthetic joint(s) - artificial |
Hives (allergic rash) | Steroid medication(s) - cortisone | Drug addiction |
Alcoholism | Unexplained weight change | Mono |
Cancer / radiation therapy | Headaches (Migraine) | Eating Disorder |
Anxiety | Osteoporosis/Osteopenia | Alzheimers/Dementia |



  1. DO YOU HAVE ANY DISEASE, CONDITION, OR PROBLEM NOT LISTED ABOVE?
    IF YES, PLEASE DESCRIBE:
  2. HAVE YOU EVER BEEN TOLD THAT YOU SHOULD NOT DONATE BLOOD?
  3. HAVE YOU EVER BLED EXCESSIVELY AFTER A CUT OR SURGERY? HAVE YOU EVER RECEIVED A BLOOD TRANSFUSION?
  4. DO YOU HAVE CLICKING OR POPPING OF THE JAW JOINT, PAIN NEAR THE EAR, DIFFICULTY OPENING MOUTH, GRIND OR CLINCH TEETH?
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WOMEN ONLY:

  1. Are you Pregnant, or is there any chance you might be pregnant?
  2. What was the date of your last normal and complete menstrual cycle?
  3. Are you nursing?
  4. If you are using Oral Contraceptives, it is important that you understand that antibiotics (and some other medications) may interfere with the effectiveness of oral contraceptives. Therefore, you will need to use mechanical forms of birth control for one complete cycle of birth control pills, after the course of antibiotics or other medication is completed. Please consult with your physician for further guidance.
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We must emphasize the seriousness of surgery or anesthesia during pregnancy
(especially early pregnancy) including harm to fetus.




ALL patients please continue on with the following information

Date of your last physical exam: Last EKG:
Are you now under a physician's care or have you been during the past 5 years including hospitalization(s)? |
If yes, for what?



Describe any complications:



Have you ever gone to sleep for an operation? (If yes, please list operation and date) |



Describe any complications:



Have you or an immediate family member ever had any serious problems associated with anesthesia? |



Are you now taking medicine of any kind? (including Blood Thinners, Aspirin, Inhalers, Ibuprofen, Vitamins, over-the-counter supplements) |
If yes, list medications and dosage (please include over the counter, herbal or homeopathic preparations):



Have you ever taken any antiresorptive drugs (for decreased bone density). These include bisphosphonates and biologic drugs. These drug include the following: Alendronate (Fosamax), Ethidronate (Didronel), Pamidronate (Aredia), Risendronate (Actonel), Tiludronate (Skelid), Zoledronic Acid (Zometa or Reclast), Clodronate (Bonefas), Ibandronate (Boniva) or Denosumab (Prolia or Xgeva). These drugs increase your risk for poor bone healing after surgery |



Do you now or have you ever used recreational drugs? (Cocaine, Marijuana, etc.) |
Please list as they can be dangerous in conjunction with anesthetic drugs:



Is there anything you would like to discuss in private with Dr. Satterfield? |
Would you like for Dr. Satterfield to pray for you before any needed surgery? |
What is your occupation? If a student, what school and grade?
If retired, previous occupation?



ANY FAMILY HISTORY OF:
Heart Disease | Diabetes |
Cancer | Seizures |
Bleeding Disorder | Stroke |



SOCIAL HISTORY:
Smokeless Tobacco usage? | yrs.
Smoke? | yrs. Packs per day
Alcohol Consumption: | | | | How long years



ARE YOU ALLERGIC TO OR HAVE YOU HAD AN ADVERSE REACTION TO:
Local Anesthesia (Novacain, etc.)? | Codeine or other pain killers? |
Sedatives, Barbiturates? | Latex or Rubber products? |
Aspirin or Ibuprofen? | Metal of any kind? |
Penicillin? | Chemicals or jewelry (rash or sensitivity)? |
Other Antibiotics? Please list: | Food Products? |
Other allergies or reactions? Please list: |
Do you wear dentures? |
Do you wear contact lenses? |



I certify that I fully understand the questions contained in this health history and certify that the answers are truthful and accurate.

Date Electronic Signature of Person Completing Health History



Your relationship to the patient (if you signed for the patient)


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