Health History Form
  • E-mail:
  • Today's Date:

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.

  •  
  • Name
  • Home Phone:
  • Cell Phone: Include area code
  • Address
  • City
  • State
  • Zip
  • Employer
  • Work Address
  • Work Phone
  • Date of birth:
  • Sex:
  • Male Female
  • SS# or Patient ID:
  • Emergency Contact
  • Relationship
  • Home Phone:
  • Cell Phone
  • If you are completing this form for another person, what is your relationship to that person
  • Do you have any of the following diseases or problems:
  • (Check DK if you Don't Know the answer to the question)
  • Active Tuberculosis...........................................................................................................................................................................
  • YES NO DK
  • Persistent cough greater than a 3 week duration..........................................................................................................................
  • YES NO DK
  • Cough that produces blood..................................................................................................................................................................
  • YES NO DK
  • Been exposed to anyone with tuberculosis.......................................................................................................................................
  • YES NO DK

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

Dental Information For the following questions, please mark (X) your responses to the following questions.
      • Do your gums bleed when you brush or floss?.................
      • YES NO DK
      • Are your teeth sensitive to cold, hot, sweets or pressure?
      • YES NO DK
      • Does food or floss catch between your teeth?....................
      • YES NO DK
      • Is your mouth dry?..............................................................
      • YES NO DK
      • Have you had any periodontal (gum) treatments?.............
      • YES NO DK
      • Have you ever had orthodontic (braces) treatment?..........
      • YES NO DK
      • Have you had any problems associated with previous dental treatment?..............................................................
      • YES NO DK
      • Is your home water supply fluoridated?...........................
      • YES NO DK
      • Do you drink bottled or filtered water?...............................
      • YES NO DK
      • If yes, how often? Check one:
      • DAILY WEEKLY OCCASIONALLY
      • Are you currently experiencing dental pain or discomfort?
      • YES NO DK
      • Do you have earaches or neck pains?........
      • YES NO DK
      • Do you have any clicking, popping or discomfort in the jaw?.................................
      • YES NO DK
      • Do you brux or grind your teeth?..............
      • YES NO DK
      • Do you have sores or ulcers in your mouth?...........................................................
      • YES NO DK
      • Do you wear dentures or partials?.............
      • YES NO DK
      • Do you participate in active recreational activities?.......................................................
      • YES NO DK
      • Have you ever had a serious injury to your head or mouth?...................................
      • YES NO DK
      • Date of your last dental exam:
      • What was done at that time?
      • Date of last dental x-rays:

  • What is the reason for your dental visit today?

  • How do you feel about your smile?
Medical Information Please mark (X) your response to indicate if you have or have not had any of the following diseases or problems.
      • Are you now under the care of a physician?.....................
      • YES NO DK
      • Physician Name:
      • Phone:
      • Address/City/State/Zip
      • Are you in good health?......................................................
      • YES NO DK
      • Has there been any change in your general health within the past year?................................................
      • YES NO DK
      • If yes, what condition is being treated?
      • Date of last physical exam:
      • Have you had a serious illness, operation or been hospitalized in the past 5 years?
      • YES NO DK
      • If yes, what was the illness or problem?
      • Are you taking or have you recently taken any prescription or over the counter medicine(s)?
      • YES NO DK
      • If so, please list all, including vitamins, natural or herbal preparations and/or diet supplements:
 
Medical Information Please mark (X) your response to indicate if you have or have not had any of the following diseases or problems.
    • (Check DK if you Don't Know the answer to the question)
    • Do you wear contact lenses?.................................................
    • YES NO DK
    • Joint Replacement. Have you had an orthopedic total joint (hip,knee, elbow, finger) replacement?..............
    • YES NO DK
      • Date:
      • If yes, have you had any complications?
    • Are you taking or scheduled to begin taking either of the medications, alendronate (Fosamax®) or risedronate (Actonel®) for osteoporosis or Paget's disease?......
    • YES NO DK
    • Have you ever had Botox or Dermal Filler Treatment?......
    • YES NO DK
    • Since 2001, were you treated or are you presently scheduled to begin treatment with the intravenous bisphosphonates (Aredia® or Zometa®) for bone pain, hypercalcemia or skeletal complications resulting from Paget's disease, multiple myeloma or metastatic cancer?
    • YES NO DK
      • Date Treatment began
    • Do you use controlled substances (drugs)?..
    • YES NO DK
    • Do you use tobacco (smoking, snuff, chew, bidis)?............................................................
    • YES NO DK
      • If so, how interested are you in stopping? (Circle one) VERY / SOMEWHAT / NOT INTERESTED
    • Do you drink alcoholic beverages?........
    • YES NO DK
      • If yes, how much alcohol did you drink in the last 24 hours?
      • If yes, how much do you typically drink In a week?
    • WOMEN ONLY Are you: Pregnant?...................
    • YES NO DK
      • Number of weeks:
      • Taking birth control pills or hormonal replacement?.............................................
      • YES NO DK
      • Nursing?....................................................
      • YES NO DK
  • Allergies - Are you allergic to or have you had a reaction to: To all yes responses, specify type of reaction
      • Local anesthetics___________________________________________
      • YES NO DK
      • Aspirin_____________________________________________________
      • YES NO DK
      • Penicillin or other antibiotics_______________________________
      • YES NO DK
      • Barbiturates, sedatives, or sleeping pills___________________
      • YES NO DK
      • Sulfa drugs_________________________________________________
      • YES NO DK
      • Codeine or other narcotics_________________________________
      • YES NO DK
      • Metals________________________________________
      • YES NO DK
      • Latex (rubber)________________________________
      • YES NO DK
      • Hay fever/seasonal___________________________
      • YES NO DK
      • Animals_______________________________________
      • YES NO DK
      • Food__________________________________________
      • YES NO DK
      • Other_________________________________________
      • YES NO DK
  • Please mark (X) your response to indicate if you have or have not had any of the following diseases or problems.
        • Artificial (prosthetic) heart valve
        • YES NO DK
        • Previous infective endocarditis
        • YES NO DK
        • Damaged valves in transplanted heart
        • YES NO DK
        • Congenital heart disease (CHD)
        • Unrepaired, cyanotic CHD
        • YES NO DK
        • Repaired (completely) in last 6 months
        • YES NO DK
        • Repaired CHD with residual defects
        • YES NO DK
        • Except for the conditions listed above, antibiotic prophylaxis is no longer recommended for any other form of CHD.
        • Cardiovascular disease
        • YES NO DK
        • Angina
        • YES NO DK
        • Arteriosclerosis
        • YES NO DK
        • Congestive heart failure
        • YES NO DK
        • Damaged heart valves
        • YES NO DK
        • Heart attack
        • YES NO DK
        • Heart murmur
        • YES NO DK
        • Low blood pressure
        • YES NO DK
        • High blood pressure
        • YES NO DK
        • Other congenital heart defects
        • YES NO DK
        • Mitral valve prolapse
        • YES NO DK
        • Pacemaker
        • YES NO DK
        • Rheumatic fever
        • YES NO DK
        • Rheumatic heart disease
        • YES NO DK
        • Abnormal bleeding
        • YES NO DK
        • Anemia
        • YES NO DK
        • Blood transfusion
        • YES NO DK
        • If yes, date
        • Hemophilia
        • YES NO DK
        • AIDS or HIV infection
        • YES NO DK
        • Arthritis
        • YES NO DK
        • Autoimmune disease
        • YES NO DK
        • Rheumatoid arthritis
        • YES NO DK
        • Systemic lupus erythematosus
        • YES NO DK
        • Asthma
        • YES NO DK
        • Bronchitis
        • YES NO DK
        • Emphysema
        • YES NO DK
        • Sinus trouble
        • YES NO DK
        • Tuberculosis
        • YES NO DK
        • Cancer/Chemotherapy /Radiation Treatment
        • YES NO DK
        • Chest pain upon exertion
        • YES NO DK
        • Chronic pain
        • YES NO DK
        • Diabetes Type I or II
        • YES NO DK
        • Eating disorder
        • YES NO DK
        • Malnutrition
        • YES NO DK
        • Gastrointestinal disease
        • YES NO DK
        • G.E. Reflux /persistent heartburn
        • YES NO DK
        • Ulcers
        • YES NO DK
        • Thyroid problems
        • YES NO DK
        • Stroke
        • YES NO DK
        • Glaucoma
        • YES NO DK
        • Hepatitis, jaundice or liver disease
        • YES NO DK
        • Epilepsy
        • YES NO DK
        • Fainting spells or seizures
        • YES NO DK
        • Neurological disorders
        • YES NO DK
        • If yes, specify
        • Sleep disorder:
        • Do you Snore?
        • YES NO DK
        • Do you wear a CPAP?
        • YES NO DK
        • Mental health disorders
        • YES NO DK
        • specify
        • Recurrent Infections
        • YES NO DK
        • Type of infection
        • Kidney problems
        • YES NO DK
        • Night sweats
        • YES NO DK
        • Osteoporosis
        • YES NO DK
        • Persistent swollen glands in neck
        • YES NO DK
        • Severe headaches/ migraines
        • YES NO DK
        • Severe or rapid weight loss
        • YES NO DK
        • Sexually transmitted disease
        • YES NO DK
        • Excessive urination
        • YES NO DK
    • Has a physician or previous dentist recommended that you take antibiotics prior to your dental treatment?
    • YES NO DK
    • Name of physician or dentist making recommendation:
    • Phone:
    • Do you have any disease, condition, or problem not listed above that you think I should know about?
    • YES NO DK
    • Please explain:

  • NOTE: Both Doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment I certify that I have read and understand the above and that the information given on this form is accurate. I understand the importance of a truthful health history and that my dentist and his/her staff will rely on this information for treating me. I acknowledge that my questions, if any, about inquiries set forth above have been answered to my satisfaction. I will not hold my dentist, or any other member of his/her staff, responsible for any action they take or do not take because of errors or omissions that I may have made in the completion of this form.

  • Signature of Patient/Legal Guardian:
  • Date:

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