Health History

Patient Information

Name *

First

Last *

Last

Birth Date *

Social Security

Address *

Address Line 2

City *

State *

Postal Code *

Home Phone

Cell Phone *

Email Address *

Work Phone

Age *

Maritial Status *

Employer *

Occupation *

No. Years Employed *

Who may we thank for referring you to our office? *

Is patient 18? *

Yes

No

If patient is a minor, give parent's or guardian's name:

Main Reason for Today's Visit:

Paragraph Text *

Do you have Insurance?

Yes

No

Insurance

Insured's Name *

First

Last *

Last

Birth Date *

Insured's Social Security *

Insured's Employer *

Insurance Co. *

Group# *

Local# *

Do you have a Previous physician? *

Yes

No

The following information is essential for this office to provide dental care in a manner that is compatible with your general health. Your cooperation in providing accurate information is necessary to meet your dental needs safely and efficiently. Incorrect information can be dangerous to your health.

Name of Physician *

Phone Number *

Address *

City *

State *

Postal Code *

Date of Last Visit *

Reason for Last Visit *

Health History

For the following, fill in the answer to each question in the space provided. If the question is not understood, you are not certain of the answer, or have any question, indicate so in the space, and discuss the matter with the doctor. All questions must be answered.

Are you currently under the care of a physician? If yes, for what reason or condition? *

Are you currently taking any medication? If yes, what medication and for what reason or condition? *

Please indicate the specific condition if you have ever had or been treated for:

Rheumatic fever, rheumatic heart disease, heart murmur or congenital heart disease? *

Yes

No

Heart trouble, heart attack, angina, pacemaker, heart surgery, or irregular beats? *

Yes

No

Stomach or intestinal disease? *

Yes

No

Arthritis of rheumatism? *

Yes

No

Abnormal blood pressure, excessive bleeding, or anemia? *

Yes

No

Are you allergic to, or have you reacted adversely to any of the following? *

If allergic to other antibiotics please list here:

If you are allergic to, or have reacted adversely to anything other than whats listed above please list here:

Breathing problems, asthma, tuberculosis, or hay fever? *

Yes

No

Tumors or growths? *

Yes

No

Cancer, X-ray treatments, or chemotherapy? *

Yes

No

A stroke, convulsions, or fainting spells? *

Yes

No

Diabetes? *

Yes

No

Kidney problems or renal dialysis? *

Yes

No

Venereal disease (syphilis, gonorrhea or herpes)? *

Yes

No

Artificial joints or other prosthesis? *

Yes

No

HIV, AIDS, or ARC? *

Yes

No

Hepatitis, jaundice, or liver disease? *

Yes

No

For women: are you pregnant? *

Yes

No

Are you on a special diet? *

Yes

No

If yes, for what reason and describe:

Do you smoke? *

Yes

No

If yes, describe type and quantity

Have you ever consulted or been treated by a psychiatrist, psychologist or counselor? *

Yes

No

If yes, describe:

Have you ever had a major operation or hospitalization? *

Yes

No

If yes, describe:

Have you ever had a serious injury to your head or neck? *

Yes

No

If yes, describe:

Have you ever had a blood transfusion? *

Yes

No

If yes, when and how much:

Dental History

In respect to any previous dental treatment, please check if you:

Have you ever fainted? *

Yes

No

Had an allergic reaction? *

Yes

No

Had abnormal bleeding? *

Yes

No

Are any of your teeth sensitive to heat, cold, or pressure? *

Yes

No

Do you grind your teeth or clench your jaws? *

Yes

No

Do you have pain or clicking in the jaw joint around ear? *

Yes

No

Are there any sores or growths in your mouth? *

Yes

No

Do your gums bleed on brushing or eating? *

Yes

No

Any other complications during or following dental treatment? *

Yes

No

If yes, describe:

Date of your last visit to a dentist: *

Reason for your last visit (or series of visits): *

NOTE: A change In your health status should be reported to the office at the earliest possible time.

To the best of my knowledge, the foregoing questions have been accurately answered. Permission To Release Health Information: I grant the right to the dentist to release health information obtained from me, and information about my dental treatment to third party payors, and/or other health practitioners.

Person completing form: *

Clear

Are you someone other than the patient? *

Yes

No

Please sign:

Clear