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 *

Month Day Year
Date
Physician's Name *

First Name Last Name
Physician's Phone Number *

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

Anesthetics Aspirin Codeine Tetracycline Erythromycin Jewelry/Metal Penicillin Latex
Please list any prescribed, over-the-counter, vitamins, or supplemental drugs:
Do you take antibiotics or pre-medication before your dental appointments? *

Yes No
Have you ever taken Fosamax or any other Bisphosphonate? *

Yes No
Do you smoke or use tobacco? *

Yes No
Have you been told you snore or hold your breath while sleeping? *

Yes No
Do you wake up gasping for breath, have sleep apnea, or use a C-Pap machine? *

Yes No
Do you clench or grind your teeth, or wake up with a headache? *

Yes No
Do you now or have you ever experience pain/discomfort in your jaw joint (TMJ/TMD)? *

Yes No
Have you ever had any of the following diseases or medical conditions? Please check all that apply. *

Anemia Arthritis Artificial Bones/Joints/Valves Asthma Autoimmune Diseases Blood Transfusion Cancer/Chemotherapy Congenital Heart Defect Diabetes Difficulty Breathing Drug/Alcohol Abuse Emphysema/Glaucoma Epilepsy/Seizure/Fainting Fever Blisters/Herpes Heart Attack/Stroke Heart Murmur Heart Surgery/Pacemaker Hemophilia/Bleeding Hepatitis High Blood Pressure HIV/AIDS Kidney Problems Low Blood Pressure Mitral Valve Prolapse Psychiatric Treatment Radiation Treatment Rheumatic/Scarlet Fever Severe/Frequent Headaches Shingles Sickle Cell Disease/Traits Sinus Problems Thyroid Tuberculosis Ulcers/Colitis Venereal Disease None of The Above
Please list any other diseases or medical conditions you may have or have had:
Females Only:

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

Yes No
Pregnant?

Yes No
Nursing?

Yes No
New Patients Only:

Please respond to the following questions.
What brings you to our office today?
Are you currently in pain?

Yes No
If so, where in your mouth is the pain located?
Do you like your smile?

Yes No
Do your gums bleed?

Yes No
Have you ever had periodontal disease?

Yes No
Have you ever had problems with any previous dental treatment?

Yes No
How many times per day do you brush?
How many times per day do you floss?
Do you use a manual or electric toothbrush?

Manual Electric
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 *

Month Day Year
Should be Empty:

Welcome to Artisan Dentistry!

Females Only:

New Patients Only: