Are you now under the care of a physician?
Physician’s Name: Phone: include area code
( )
Address/City/State/Zip:
Are you in good health?
Has there been any change in your
general health within the past year?
If yes, what condition is being treated?
Date of last physical exam:
Pharmacy Name
Phone ( )
List any medications you are currently taking and the correlating diagnosis:
Medications
YesNoDK
Medical Information
Please mark (X) your response to indicate if you have or have had any of the following diseases or problems.
YesNoDK
Have you had a serious illness, operation or been
hospitalized in the past 5 years?
If yes, what was the illness or problem?
Do your gums bleed when you brush or floss?
Are your teeth sensitive to cold, hot, sweets or pressure?
Does food or floss catch between your teeth?
Is your mouth dry?
Have you had any periodontal (gum) treatments?
Have you ever had orthodontic (braces) treatment?
Have you had any problems associated with
previous dental treatment?
Is your home water supply fluoridated?
Do you drink bottled or filtered water?
If yes, how often? Circle one: DAILY / WEEKLY / OCCASIONALLY
Are you currently experiencing dental pain or discomfort?
What is the reason for your dental visit today?
How do you feel about your smile?
Dental Information
YesNoDK
For the following questions, please mark (X) your responses to the following questions.
Do you have earaches or neck pains?
Do you have any clicking, popping or
discomfort in the jaw?
Do you brux or grind your teeth?
Do you have sores or ulcers in your mouth?
Do you wear dentures or partials?
Do you participate in active recreational activities?
Have you ever had a serious injury to
your head or mouth?
Date of your last dental exam:
What was done at that time?
Date of last dental x-rays:
YesNoDK
Do you have any of the following diseases or problems:
(Check DK if you Don’t Know the answer to the question)
Active Tuberculosis
Persistent cough greater than a 3 week duration
Cough that produces blood
Been exposed to anyone with tuberculosis
If you answer yes to any of the 4 items above, please stop and return this form to the receptionist.
YesNoDK
Health History Form
E-mail: Today’s Date:
Name: Home Phone:
include area code Business/Cell Phone: include area code
( ) ( )
Mailing Address:
City State Zip
Occupation: Height: Weight: Date of birth: Sex: M F
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?
Your Name Relationship
include area codes
Last First Middle
Heart murmur
Mitral valve prolapse
Artificial heart valves
Rheumatic fever
Cardiovascular disease
Angina
Arteriosclerosis
Congestive heart failure
Coronary artery disease
Damaged heart valves
Heart attack
Low blood pressure
High blood pressure
Congenital heart defects
Pacemaker
Rheumatic heart disease
Abnormal bleeding
Anemia
Blood transfusion
If yes, date:
Hemophilia
AIDS or HIV infection
Arthritis
Autoimmune disease
Rheumatoid arthritis
Systemic lupus
erythematosus
Asthma
Bronchitis
Emphysema
Sinus trouble
Tuberculosis
Cancer/Chemotherapy/
Radiation Treatment
Chest pain upon exertion
Chronic pain
Diabetes Type I or II
Eating disorder
Malnutrition
Gastrointestinal disease
G.E. Reflux/persistent
heartburn
Ulcers
Thyroid problems
Stroke
Glaucoma
Hepatitis, jaundice or
liver disease
YesNo DK 
YesNoDK
Epilepsy
Fainting spells or seizures
Neurological disorders
If yes, Specify:
Sleep disorder
Mental health disorders
Specify:
Recurrent infections
Type of infection:
Kidney problems
Night sweats
Osteoporosis
Persistent swollen glands
in neck
Severe headaches/
migraines
Severe or rapid weight loss
Sexually transmitted disease
Excessive urination
YesNoDK
(Check DK if you Don’t Know the answer to the question)
Are you taking or scheduled to begin taking either
of the medications, alendronate (Fosamax®) or
risedronate (Actonel®) for osteoporosis or
Paget’s disease?
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?
Date Treatment began:
Joint Replacement. Have you had an orthopedic total joint (hip, knee,
elbow, finger) replacement?
Date: If yes, have you had any complications?
Allergies - Are you allergic to or have you had a reaction to:
Local anesthetics
Aspirin
Penicillin or other antibiotics
Barbiturates, sedatives, or sleeping pills
Sulfa drugs
Codeine or other narcotics
YesNoDK
Please mark (X) your response to indicate if you have or have not had any of the following disease or problems.
Do you use controlled substances (drugs)?
Do you use tobacco (smoking, snuff, chew, bidis)?
If so, how interested are you in stopping?
(Circle one) VERY / SOMEWHAT / NOT INTERESTED
Do you drink alcoholic beverages?
If yes, how much alcohol did you drink in the last 24 hours?
If yes, how much do you typically drink in a week?
Metals
Latex (rubber)
Iodine
Hay fever/seasonal
Animals
Food
Other
YesNoDK
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 have made in the completion of this form.
Signature of Patient/Legal Guardian: Date:
Has a physician or previous dentist recommended that you take antibiotics prior to your dental treatment?
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?
Please explain:
WOMEN ONLY Are you:
Pregnant?
Number of weeks: _____________
Taking birth control pills or hormonal replacements?
Nursing?
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