Medical and Dental Health History Form

Medical and Dental Health History Form
Curtis E. Hahn, D.D.S. 4992 Wilson Avenue | Grandville, MI 49418 616.534.0135 | rivertowndental.com

Please fill out the electronic form below. Alternatively, you can view / download / print our form for manual submission using the link below.

Medical & Dental Health History
Last Name
First Name
Middle Initial
Date of birth:

MonthDayYear
Cell Phone Number
Please enter a valid phone number.
Email
example@example.com
Within the past year, have there been any changes in your general health?

YesNo
Have you been hospitalized within the last 5 years due to an illness, injury or other condition?

YesNo
If yes, please explain:
What is the date (or approximate date) of your last medical exam?

MonthDayYear
Date
Your Primary Care Physician's name, address and phone number:
Preferred pharmacy location and phone number
Are you currently taking any prescription or non-prescription medications (including vitamins, supplements, or natural products/remedies)?

YesNo
Please list any medications you are currently taking, one medication per line:
(WOMEN ONLY) Are you taking birth control?

YesNo
(WOMEN ONLY) Are you pregnant?

YesNo
If yes, when is the due date Date Date
Please indicate if you have experienced any of the following please check all that apply.

AIDSAcid Reflux/GERDAllergy: ErthromycinAllergy: LatexAllergy: MetalsAllergy: OtherAllergy: PenicillinAllergy: Sulfa DrugsAnemiaAnginaAnorexia/BulimiaAnxietyArthritisArtif. Heart ValveArtificial JointsAsthmaAvoid NSAID DrugsBisphosphonate RxCancerCold SoresCongen Heart DiseaseCosmetic SurgeryDepressionDiabetesDifficulty SleepingDizzinessEmphysema/COPDEpilepsy/SeizuresFaintingGlaucomaHIVHPV/STDHay FeverHead InjuriesHeadachesHeart AttackHeart DiseaseHeart MurmurHeart SurgeryHemophiliaHepatitisHypertension-High BPJaw InjuryJaw Joint PainKidney DiseaseLaryngospasmLiver DiseaseMitral Valve ProlapNervous DisordersPacemakerPre-MedPsychiatric TreatmntRadiation TreatmentRheumatic FeverSinus ProblemsSleep ApneaSnoringStrokeThyroid DiseaseTuberculosis (TB)TumorUlcers
Additional details on positive answers above:
Do you have any other health issues or allergies that need further clarification?

YesNo
If yes, please explain:
Please mark any of the following to indicate Yes in response to the question:

Have your ever been dependent on drugs or alcohol?Are you on a salt restricted diet?Has your physician ever recommended taking antibiotics prior to dental appointments?Have you ever had complications following dental treatment?Do you smoke, vape or use other forms tobacco or marijuana?Do you require the use of corrective lenses (contacts or glasses)?Do you have difficulty hearing or require the use of hearing aids?Do you have any other conditions, diseases, etc., not listed above that we should be aware of?
If any of the previous questions are marked, please explain:
How frequently do you brush your teeth?

3 (+) a dayTwice a dayOnce a dayWeeklySeldom
How frequently do you floss your teeth?

Once a day2-6 weekly1-6 monthlySeldomNever
What was the date of your last dental visit?
What is the name and location of your previous dentist?
Do you have dental anxiety?

YesNo
Please mark any of the following to indicate Yes in response to the question:

Are any of your teeth currently causing you pain?Have you ever been diagnosed with or been treated for gum/periodontal disease?Do your gums bleed when you brush or floss?Do your teeth experience sensitivity to cold or hot temperatures?Do you grind your teeth (either consciously or during sleep?)Are any of your teeth loose, or are you concerned about any teeth loosening?Do you currently have any dental implants, dentures, or partials?Do you have any dental appliances (retainers,bite guard)?Have you had orthodontic treatment in the past?
If any of the previous questions are marked, please explain:
To the best of my knowledge, all of the preceding information is true and correct. If I ever have a change in my health, I will inform the office at my next dental appointment without fail.
Authorization
I hereby certify that I have read and understand the previous information and that it is accurate and true to the best of my knowledge. I acknowledge that providing incorrect and/or inaccurate information has the potential of being hazardous to my health.

I authorize the diagnosis of my dental health by means of radiographs, study models, photographs, or other diagnostic aids deemed appropriate.

I authorize the dentist to release any information including the diagnosis and records of treatment or examination for myself and my dependent(s) to third-party insurance carriers, payors, and/or healthcare practitioners.

I authorize the payment from my insurance carrier to submit payment directly to the dentist or dental practice to be applied directly to any outstanding balance on my account.

I understand that I am financially responsible for any outstanding balance for services provided that are not fully covered by insurance, and I may be billed for this remaining balance. I consent and agree to be financially responsible for payment of all services rendered on my behalf or on behalf of my dependents (if any).
Signature of patient, parent, or legal guardian*

Clear
Date:

MonthDayYear
Relationship to Patient:
Everyone deserves a healthy smile!
Should be Empty:

Medical and Dental Health History Form

Authorization