Health History Form

As required by law, our office adheres to written policies and procedures to protect the privacy of information about you that we create, receive or maintain. Your answers are for our records only and will be kept confidential subject to applicable laws. Please note that you will be asked some questions about your responses to this questionnaire and there may be additional questions concerning your health. This information is vital to allow us to provide appropriate care for you. This office does not use this information to discriminate.

If you are completing this form for another person, what is your relationship to that person?

(Check DK if you Don't Know the answer to the question)

If you answer yes to any of the 4 items above, please stop and return this form to the receptionist.

For the following questions, please mark (X) your responses to the following questions.

Please mark (X) your response to indicate if you have or have not had any of the following diseases or problems.

Please mark (X) your response to indicate if you have or have not had any of the following diseases or problems

Congenital heart disease (CHD)

Except for the conditions listed above, antibiotic prophylaxis is no longer recommended for any other form of CHD