HEALTH HISTORY CHECKLIST

PAST MEDICAL HISTORY

Respiratory Problems (“breathing problems”) Neurologic Problems
 Asthma  Cerebrovascular Accident (“Stroke”)
 Tuberculosis  Transient Ischemic Attack – TIA (“mini stroke”)
 Sleep apnea  Multiple sclerosis
 Bronchitis/Emphysema/COPD  Epilepsy/Seizure disorder
Additional info:  Neuropathy/Neuropathic pain (“nerve pain”)
Additional info:
Hematologic Problems (“blood problems”
 Anemia Endocrine Problems
 Sickle cell disease/trait  Diabetes (“sugar diabetes”)
 HIV disease/AIDS  Thyroid disorder
 Bleeding disorders (“blood too thick or too thin”) Additional info:
 Leukemia/lymphoma (“blood cancer”)
 Coumadin/warfarin treatment (blood thinners) Other Problems
Additional info:  Renal/Kidney disease
 Dialysis
Cardiovascular Problems  Organ transplant
 Hypertension (“high blood pressure”)  Cancer
 Angina (“chest pain”)  Radiation/Chemotherapy treatment
 Myocardial infarction (“heart attack”)  Arthritis
 Prosthetic cardiac valve (“artificial heart valve”)  Artificial joint (“joint replacement”)
 Congestive heart failure  Use/used a bisphosphonate medication for osteoporosis or bone
 Coronary Artery Bypass Surgery - CABG (“heart bypass surgery”) cancer treatment
 Cardiac stent surgery Additional info:
 Pacemaker/Defibrillator
 Infective endocarditis (“heart infection”) MEDICATIONS
Additional info: Name/Dosage Classification Dental Implications

Gastrointestinal Problems
 Hepatitis/Jaundice
 Liver disease
 Gastroesophageal Reflux Disease (“reflux”)
 Ulcers
Additional info:
 HEALTH HISTORY CHECKLIST

REVIEW OF SYSTEMS Gastrointestinal

 Nausea/Vomiting
General:  Diarrhea/Constipation
 Weight loss/gain  Heart burn
 Fatigue
 Fever/chills Musculoskeletal
 Insomnia  Myalgia (“Muscle pain”)
 Arthralgia (“Joint pain”)
HEENT  Stiffness
 Tinnitus (“ringing in ears”)
 Ear pain Neurologic
 Rhinorrhea (“runny nose”)  Dizziness
 Epistaxis (“nose bleeds”)  Syncope (“Fainting”)
 Mouth sores  Weakness
 Headache  Numbness/tingling
 Blurry vision/Double vision  Tremor
 Vision changes
 Numbness/Tingling of face Hematologic
 Dysphagia (“difficulty swallowing”)  Fatigue
 Bruising
Cardiac  Infections
 Chest pain  Lymphadenopathy (“swollen glands”)
 Heart palpitations
 Exercise intolerance Endocrine
 Claudication (“leg cramps/pain”)  Heat/cold intolerance
 Diaphoresis (“Sweating”)
Respiratory  Polyuria (“Frequent urination”)
 Cough  Polydipsia (“Thirst”)
 Dyspnea (“shortness of breath”)  Polyphagia (“increase in appetite”)
 Wheezing
Psychiatric
 Nervousness
 Stress
 Sadness/depression