Health History Form

Email*

example@example.com

Today's Date*

Date

Patient Name*

First NameLast Name

Home Phone Number*

Please enter a valid phone number.

Business/Cell Phone Number

Please enter a valid phone number.

Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Occupation*

Height*

Weight*

Date of Birth*

Date

Sex*

MaleFemale

Social Security Number*

Emergency Contact*

Emergency Contact Relationship*

Emergency Contact Phone Number*

Please enter a valid phone number.

Name of person filling out form, if different than patient*

If you are completing this form for another person, what is your relationship to that person?*

Do you have any of the following diseases or problems*

	Yes	No	Not Sure
Active Tuberculosis
Persistent cough greater than a 3 week duration
Cough that produces blood
Been exposed to anyone with tuberculosis

Dental Information

Please indicate your answers to the following questions*

	Yes	No	Not Sure
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?
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?

What is the reason for your dental visit today?*

How do you feel about your smile?*

Date of your last dental exam*

Date

What was done at that time?*

Date of last dental x-rays

Medical Information

Are you now under the care of a physician?*

YesNoNot Sure

Physician Name*

Physician Phone Number*

Physician Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Are you in good health?*

YesNoNot Sure

Has there been any change in your general health within the past year?*

YesNoNot Sure

If yes, what condition is being treated?

Date of last physical exam*

Date

Have you had a serious illness, operation or been hospitalized in the past 5 years?*

YesNoNot Sure

If yes, what was the illness or problem?

Are you taking or have you recently taken any prescription or over the counter medicine(s)?*

YesNoNot Sure

If so, please list all, including vitamins, natural or herbal preparations and/or dietary supplements

Do you wear contact lenses?*

YesNo

Have you had an orthopedic total joint (hip, knee, elbow, finger) replacement?*

YesNo

If yes, what was the date?

Date

If yes, have you had any complications?

Are you taking or scheduled to begin taking an antiresorptive agent (like Fosamax®, Actonel®, Atelvia, Boniva®, Reclast, Prolia) for osteoporosis or Paget’s disease?*

YesNoNot Sure

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?*

YesNoNot Sure

If yes, date treatment began

Date

Are you allergic to or have you had a reaction to:*

	Yes	No	Not Sure
Local anesthetics
Aspirin
Penicillin or other antibiotics
Barbiturates, sedatives, or sleeping pills
Sulfa drugs
Codeine or other narcotics

If you answered yes to any of the above, please specify type of reaction

Please indicate if you have or have not had any of the following diseases or problems*

	Yes	No	Not Sure
Artificial (prosthetic) heart valve
Previous infective endocarditis
Damaged valves in transplanted heart
Congenital heart disease (CHD): Unrepaired, cyanotic CHD
CHD: Repaired (completely) in last 6 months
CHD: Repaired CHD with residual defects
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 disorder
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

Has a physician or previous dentist recommended that you take antibiotics prior to your dental treatment?*

YesNoNot Sure

Name of physician or dentist making recommendation

Phone number of physician or dentist making recommendation

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