HEALTH HISTORY INFORMATION FORM

Welcome to Artisan Dentistry!

HEALTH HISTORY INFORMATION FORM
First Name*
Last Name*
Preferred Pronoun:
Email*
example@example.com
Date of Birth*

MonthDayYear
Date
Physician's Name*

First NameLast Name
Physician's Phone Number*

Area CodePhone Number
Are you allergic to any of the following? Please check all that apply.

AnestheticsAspirinCodeineTetracyclineErythromycinJewelry/MetalPenicillinLatex
Please list any prescribed, over-the-counter, vitamins, or supplemental drugs:
Do you take antibiotics or pre-medication before your dental appointments?*

YesNo
Have you ever taken Fosamax or any other Bisphosphonate?*

YesNo
Do you smoke or use tobacco?*

YesNo
Have you been told you snore or hold your breath while sleeping?*

YesNo
Do you wake up gasping for breath, have sleep apnea, or use a C-Pap machine?*

YesNo
Do you clench or grind your teeth, or wake up with a headache?*

YesNo
Do you now or have you ever experience pain/discomfort in your jaw joint (TMJ/TMD)?*

YesNo
Have you ever had any of the following diseases or medical conditions? Please check all that apply.*

AnemiaArthritisArtificial Bones/Joints/ValvesAsthmaAutoimmune DiseasesBlood TransfusionCancer/ChemotherapyCongenital Heart DefectDiabetesDifficulty BreathingDrug/Alcohol AbuseEmphysema/GlaucomaEpilepsy/Seizure/FaintingFever Blisters/HerpesHeart Attack/StrokeHeart MurmurHeart Surgery/PacemakerHemophilia/BleedingHepatitisHigh Blood PressureHIV/AIDSKidney ProblemsLow Blood PressureMitral Valve ProlapsePsychiatric TreatmentRadiation TreatmentRheumatic/Scarlet FeverSevere/Frequent HeadachesShinglesSickle Cell Disease/TraitsSinus ProblemsThyroidTuberculosisUlcers/ColitisVenereal DiseaseNone of The Above
Please list any other diseases or medical conditions you may have or have had:
Other Information:

Please respond to the following questions if they apply.
Are you taking any hormones or birth control?

YesNo
Pregnant?

YesNo
Nursing?

YesNo
New Patients Only:

Please respond to the following questions.
How did you hear about us?
Example: Specialist/Friend/Online
What brings you to our office today?
Are you currently in pain?

YesNo
If so, where in your mouth is the pain located?
Do you like your smile?

YesNo
Do your gums bleed?

YesNo
Have you ever had periodontal disease?

YesNo
Have you ever had problems with any previous dental treatment?

YesNo
How many times per day do you brush?
How many times per day do you floss?
Do you use a manual or electric toothbrush?

ManualElectric
My signature below indicates that the information that I have given above is correct to the best of my knowledge. I also understand that it is my responsibility to inform the office of any changes in my medical status.
Patient/Guardian Signature

Clear
Signer's Name*
Today's Date*

MonthDayYear
Should be Empty:

Welcome to Artisan Dentistry!

Other Information:

New Patients Only: