Dental/Medical Health History

• Legal Form Number: BP-A0787
• Date: 2010-06
• Year: 2010
• Section: Federal Bureau of Prisons

DENTAL/MEDICAL HEALTH HISTORYU.S. DEPARTMENT OF JUSTICE

FEDERAL BUREAU OF PRISONS

BP-A0787

JUN 10

1. Are you currently taking any medication?

If so, what? _____________________________________________________________________ _____ No

Language template provided in Spanish , or .

_____ Yes

_____ No

_____ Yes

2. Are you allergic to or have you had a reaction to any medication or drug?

If so, what? ______________________________________________________________________

_____ No

_____ Yes

3. Have you been under the care of a physician during the past two years?

If so, what? ______________________________________________________________________

_____ No

_____ Yes

4. Have you been hospitalized in the past two years?

If so, what? ______________________________________________________________________

_____ No _____ Yes

5. Do you have or have you ever had a heart murmur or been treated for a heart condition?

_____ No _____ Yes

6. Have you ever been treated for a tumor, growth, or cancer?

_____ No _____ Yes

7. Have you ever had excessive or prolonged bleeding as result of a medical condition or medication

(ex. Hemophilia or blood thinners)?

_____ No _____ Yes

8. Do you have a latex allergy?

_____ No _____ Yes

9. Do you currently use tobacco products?

_____ No _____ Yes

10. WOMEN ONLY: Are you pregnant

Check any of the following that you have had:

____ Congenital hear defects

____ Heart attack or heart problems

____ Stroke

____ Rheumatic fever

____ Mitral Valve Prolapse

____ Anemia (blood problems)

____ Thyroid problems

____ Chronic bronchitis

____ STD (syphilis, gonorrhea, herpes)

____ Angio edema

____ Arthritis

____ Artificial heart valve

____ Hepatitis ( ___ A ___ B ___ C )

____ Any type of transplant

____ Steroid treatment

____ Sickle Cell Anemia

____ Angina

____ High blood pressure

____ Heart pacemaker

____ Glucose - 6 - phosphate dehydrogenase deficiency

____ Epilepsy or seizures

____ Diabetes

____ AIDS or HIV infection

____ Emphysema

____ Tuberculosis (TB)

____ Psychiatric treatment

____ Artificial joint

____ Radiation therapy

____ Asthma

Do you have any disease, condition, or problem not listed? _________________________________________

Check any of the following that you have had or applies to you:

____ Sensitive teeth

____ Bleeding gums

____ Food impaction

____ Pain around ear

____ Tooth ache

____ Wear partial dentures

____ unusual sounds while eating

____ Snoring

____ Blisters on lips or mouth

____ Clenching or grinding

____ Tooth ache

____ Swelling or lumps in mouth/throat

____ Burning tongue

____ Bad breath

____ Decayed teeth

____ Loose teeth

____ Wear dentures

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Reg. No. :

Date:

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