www.myparkdentalcare.com - Health History Form

Health History Form
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.
Patient Name *

First Name Last Name
Email *
example@example.com
Address *
Street, City, State, Zip
Home Phone
Business/Cell Phone: *
Occupation
Date of Birth *

Month Day Year
Date
SEX *

Male Female
SS# or Patient ID
Emergency Contact
Name *
Relationship *
Home Phone
Cell Phone *
Do you complete this form for another person? *

Yes No
Your Name *

First Name Last Name
Relationship *
Do you have any of the following diseases or problems?
(Select "Don’t Know" if you Don’t Know the answer to the the question)
Active Tuberculosis *
Persistent cough greater than a 3 week duration *
Cough that produces blood *
Been exposed to anyone with tuberculosis *
If your answer is "Yes" to any of the 4 items above, please stop filling the form and call our office
Dental Information
Please Select your responses to the following questions.
Do your gums bleed when you brush or floss? *
Are your teeth sensitive to cold, hot, sweets or pressure? *
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? Select one *
Are you currently experiencing dental pain or discomfort? *
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

Month Day Year
Date
What was done at that time?
Date of last dental x-rays

Month Day Year
Date
What is the reason for your dental visit today?
How do you feel about your smile?
Medical Information
Please select 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? *
Physician Name

First Name Last Name
Phone Number
Address

Street, City, State

Street Address Line 2
Are you in good health? *
Describe *
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 *

Month Day Year
Date
Have you had a serious illness, operation or been hospitalized in the past 5 years? *
If yes, what was the illness or problem? *
Are you taking or have you recently taken any prescription or over the counter medicine(s)? *
If so, please list all, including vitamins, natural or herbal preparations and/or dietary supplements
Do you wear contact lenses? *
Have you had an orthopedic total joint (hip, knee, elbow, finger) replacement? *
If yes, have you had any complications? *
Date
Are you taking or scheduled to begin taking an antiresorptive agent (like Fosamax®, Actonel®, Atelvia, Boniva®, Reclast, Prolia) for osteoporosis or Paget’s disease? *
Since 2001, were you treated or are you presently scheduled to begin treatment with an antiresorptive agent (like Aredia®, Zometa®, XGEVA) for bone pain, hypercalcemia or skeletal complications resulting from Paget’s disease, multiple myeloma or metastatic cancer? *
Date Treatment Began
Do you use controlled substances (drugs)? *
Do you use tobacco (smoking, snuff, chew, bidis)? *
If so, how interested are you in stopping? *
Do you drink alcoholic beverages? *
How much alcohol did you drink in the last 24 hours? *
How much do you typically drink in a week? *
Are you Pregnant? *
Number of weeks *
Taking birth control pills or hormonal replacement? *
Nursing? *
Are you allergic to or have you had a reaction? Specify the type of reaction in comments box

Local anesthetics Aspirin Penicillin or other antibiotics Barbiturates, sedatives, or sleeping pills Sulfa Drugs Codeine or other narcotics Metals Latex (Rubber) Iodine Hay Fever/Seasonal Animals Food Other I HAVE NO KNOWN DRUG ALLERGIES
Specify the type of reaction
Indicate if you have had any of the following diseases by checking the box *

Artificial (prosthetic) heart valve Previous infective endocarditis Damaged valves in transplanted heart Congenital heart disease (CHD) Cardiovascular Disease Angina Arteriosclerosis Congestive Heart Failure Damaged Heart Valves Heart Attack Heart Murmur Low Blood Pressure High Blood Pressure Other congenital heart defects Mitral Valve Prolapse Pacemaker Rheumatic Fever Rheumatic Heart Disease Abnormal Bleeding Anemia Blood Transfusion 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 Epilepsy Fainting Spells or seizures Neurological Disorders Sleep Disorder Do you snore? Mental Health Disorders Recurrent Infections Kidney Problems Night Sweats Osteoporosis Persistent swollen glands in neck Severe headaches/migraines Severe or rapid weight loss Sexually Transmitted Disease Excessive Urination None of the above apply to me
Blood Transfusion Date *
Specify Neurological Disorders *
Specify Mental Health Disorders *
Type of Recurrent Infections *
Has a physician or previous dentist recommended that you take antibiotics prior to your dental treatment? *
Name of physician or dentist making recommendation
Phone Number
Do you have any disease, condition, or problem not listed above that you think I should know about? *
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
Patients Name *

First Name Last Name
Date *

Month Day Year
Date
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