Dental Health Questionnaire

Name

Date

Primary Physician’s Name

Phone Number

History of recent hospitalization

Allergies, including to MEDICATIONS or LATEX

Medications presently taking: (including aspirin, etc.)

History of taking Bisphosphonate (e.g. Actonel, Altevia, Boniva, Fosamax, Reclast and Zometa)

Yes No

Have you ever been pre-medicated for dental treatment?

Yes No

If yes, Please explain

Family History of

Heart Disease

Diabetes

Cancer

Seizures

Social History: Occupation

Type and Frequency of Tobacco Use

Alcohol consumption

Do you have or have you ever had:

(Hepatitis), What type?

Cancer/Radiation Therapy

Yes No Don't Know

1. Have you ever been told that you should not donate blood?

Yes No

2. Females: Are you currently taking Birth Control Pills

Yes No

Are you or might you be pregnant?

Yes No

Estimate Delivery

3. Do you have any disease, condition or problem not listed above

Yes No

If yes, Please describe

4. Have you had problems with prior dental treatment?

Yes No

If yes, Please describe

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Patient Signature

Date

Health Updates (I have reviewed my Health History and confirm that it accurately states past and present conditions.)

Date

Patient Signature

Changes to Health History

Dentist Initials

Provider Signature

Date

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