Health History

Patient First Name

Patient Last Name

Birth Date

Gender

Male Female Other

Other

Medical History

Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions.

Are you in good health?

Yes No

Have there been any changes in your general health within the past year?

Yes No

If yes, please explain

Physician’s Name

Phone #

Date of Last Physical Exam

Address

City

State

Zip Code

Are you under a physician’s care now?

Yes No

Have you ever been hospitalized for any surgical operation or serious illness?

Yes No

If yes, please describe

Are you taking any medicine(s) including non-prescription medicine?

Yes No

If yes, please list

Have you had any abnormal bleeding?

Yes No

Have you ever taken Fen-Phen or Redux?

Yes No

Do you use tobacco?

Yes No

Do you or have you ever used controlled substances?

Yes No

Are you wearing contact lenses?

Yes No

Do you have a persistent cough or throat clearing not associated with a known illness (lasting more than 3 weeks)?

Yes No

FOR WOMEN ONLY

Are you...

Pregnant?

Yes No

Nursing

Yes No

Taking Oral Contraceptives?

Yes No

ARE YOU ALLERGIC TO ANY OF THE FOLLOWING?

Aspirin

Yes No

Metal

Yes No

Penicillin

Yes No

Latex

Yes No

Codeine

Yes No

Sulfa Drugs

Yes No

Acrylic

Yes No

Local Anesthetics

Yes No

Do you have any other allergy not listed above?

Yes No

If yes, please list

DO YOU HAVE OR HAVE YOU EVER HAD ANY OF THE FOLLOWING?

AIDS/ HIV Positive

Yes No

Alzheimer’s Disease

Yes No

Anaphylaxis

Yes No

Anemia

Yes No

Angina

Yes No

Arthritis/Gout

Yes No

Artificial Heart Valve

Yes No

Artificial Joint

Yes No

Asthma

Yes No

Blood Disease

Yes No

Blood Transfusion

Yes No

Breathing Problem

Yes No

Bruise Easily

Yes No

Cancer

Yes No

Chemotherapy

Yes No

Chest Pains

Yes No

Cold Sores/Fever Blisters

Yes No

Congenital Heart Disorder

Yes No

Convulsions

Yes No

Cortisone Medicine

Yes No

Diabetes

Yes No

Drug Addiction

Yes No

Easily Winded

Yes No

Emphysema

Yes No

Epilepsy or Seizures

Yes No

Excessive Bleeding

Yes No

Excessive Thirst

Yes No

Fainting Spells/Dizziness

Yes No

Frequent Cough

Yes No

Frequent Diarrhea

Yes No

Frequent Headaches

Yes No

Genital Herpes

Yes No

Glaucoma

Yes No

Hay Fever

Yes No

Heart Attack/Failure

Yes No

Heart Murmur

Yes No

Heart Pacemaker

Yes No

Heart Trouble/Disease

Yes No

Hemophilia

Yes No

Hepatitis A

Yes No

Hepatitis B or C

Yes No

Herpes

Yes No

High Blood Pressure

Yes No

High Cholesterol

Yes No

Hives or Rash

Yes No

Hypoglycemia

Yes No

Irregular Heartbeat

Yes No

Kidney Problems

Yes No

Leukemia

Yes No

Liver Disease

Yes No

Low Blood Pressure

Yes No

Lung Disease

Yes No

Mitral Valve Prolapse

Yes No

Osteoporosis

Yes No

Pain in Jaw Joints

Yes No

Parathyroid Disease

Yes No

Psychiatric Care

Yes No

Radiation Treatments

Yes No

Recent Weight Loss

Yes No

Renal Dialysis

Yes No

Rheumatic Fever

Yes No

Rheumatism

Yes No

Scarlet Fever

Yes No

Shingles

Yes No

Sickle Cell Disease

Yes No

Sinus Trouble

Yes No

Spina Bifida

Yes No

Stomach/Intestinal Disease

Yes No

Stroke

Yes No

Swelling of Limbs

Yes No

Thyroid Disease

Yes No

Tonsillitis

Yes No

Tuberculosis

Yes No

Tumors or Growths

Yes No

Ulcers

Yes No

Venereal Disease

Yes No

Yellow Jaundice

Yes No

Do you have any disease, condition or problem not listed above that you think I should know about?

Yes No

If yes, please explain

Dental History

Reason for today’s visit?

Date of last visit

What was done then?

How often did you visit the dentist before then?

Previous Dentist

Location

Have you had a complete series of dental x-rays taken?

Yes No

If so, when?

How often do you brush your teeth?

How often do you floss?

Is your drinking water fluoridated?

Yes No

City water or well water?

DO YOU HAVE OR HAVE YOU EVER HAD ANY OF THE FOLLOWING?

Do you feel pain in any area of your mouth

Yes No

If so, where and when?

How long has this been a problem?

Do you have any sores, lumps or bumps in or around your mouth?

Yes No

Are any of your teeth sensitive to:

Hot or Cold Sweets Biting or Chewing

Do you wear full or partial dentures?

Yes No

If so, date of placement?

Have you ever had treatment for periodontal disease?

Yes No

Do your gums bleed while brushing or flossing?

Yes No

Do you have any loose teeth?

Yes No

Do you have areas where food gets caught?

Yes No

Have you had any of the following jaw problems?

Clicking or popping Pain in jaw joint, ear or side of face Difficulty opening wide Difficulty chewing

Do you have frequent headaches?

Yes No

Do you clench or grind your teeth?

Yes No

Do you bite your lips or cheeks frequently?

Yes No

Do you or have you ever worn a night guard or bite plate?

Yes No

Have you had any head, neck or jaw injuries?

Yes No

Have you ever had prolonged bleeding after extractions or any other dental treatment?

Yes No

Have you ever had any difficult extractions in the past?

Yes No

Have you ever received oral hygiene instructions regarding the care of your teeth and gums?

Yes No

If you could change anything about the appearance of your smile, what would you change?

Form Completion

I certify that I have read and understand the above information to the best of my knowledge. The above questions have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health. I authorize the dentist to release any information including the diagnosis and the records of any treatment or examination rendered to me or my child during the period of such dental care to third party payors and/or health practitioners. I authorize and request my insurance company to pay directly to the dentist or dental group insurance benefits otherwise payable to me. I understand that my dental insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf or my dependents.

Signature of Patient, Parent or Guardian

Clear

Clear

Date

If Patient is a Minor

Form signed by

Relationship to Patient

Health History

Medical History

FOR WOMEN ONLY

ARE YOU ALLERGIC TO ANY OF THE FOLLOWING?

DO YOU HAVE OR HAVE YOU EVER HAD ANY OF THE FOLLOWING?

Dental History

DO YOU HAVE OR HAVE YOU EVER HAD ANY OF THE FOLLOWING?

Form Completion

If Patient is a Minor

Please rotate your device.