Health History Form

Today's Date

Full Name

Date of Birth

Address

City

State

Zip

Home Phone

Cell

Work

Parent's Name (If Child)

Spouse's Name

Dental Insurance

Insurance Mailing Address

Policy Number

Group Number

Subscriber

Dental Insurance Company

Employer

Social Security #

Business Address

Occupation

Person Responsible for Account

Referred By

Physician

Physician Phone #

Last Physical

Patient Medical History

1. Are you under any medical treatment now?

Yes No

2. Have you had any operations?

Yes No

If so what?

3. Have you ever had a serious accident involving head injuries?

Yes No

If Other, Please describe

Add Allergies / Medications

4. Have you ever had radiation treatment?

Yes No

5. Do you have a history of fainting?

Yes No

6. Have you ever taken Phen /Fen, Redux, or any other diet drugs?

Yes No

7. (Women) Are you pregnant?

Yes No

Patient Dental History

8. Do you have pain in or around the ear?

Yes No

9. Do you have any unhealed injuries in your mouth?

Yes No

10. Have you had any sore spots or growths in your mouth?

Yes No

11. Do you clench or grind your teeth?

Yes No

12. Do your gums bleed when you brush?

Yes No

13. When was your last full set (16 films) of x-rays?

Yes No

(When was your last full set (16 films) of x-rays?) If yes, Please specify date

14. Do you have any dental complaints? Please list

15. Have you ever had adverse reactions to: Latex?

Yes No

Novocaine?

Yes No

I have reviewed the information on this form and it is accurate to the best of my knowledge. I understand the information will be used by the dentist's to help determine the appropriate dental treatment. If there is any change in my medical status I will inform this office.

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.

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Date

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