Health History Form

Patient’s Name

Date of Birth

Gender

Height

Weight

Today's Date

An accurate and complete health history will assist in coordinating your dental care. Please speak with the doctor or staff if there are any questions about this form.

Dental History

Please describe your current dental health.

Excellent Good Fair Poor

Please describe why you are in the office today.

Have there been any changes in your dental health in the past year?

Yes No

If yes, please describe.

Are you having any dental discomfort at this time?

Yes No

If yes, please describe.

Have you had any adverse effects from dental treatment?

Yes No

If yes, please describe.

Date of last dental visit?

DENTAL HISTORY - Do you have or have you ever had any of the following:

Bleeding, sore gums?

Yes No

Shifting in bite?

Yes No

Unpleasant taste/bad breath?

Yes No

Change in bite?

Yes No

Swelling/lumps in mouth?

Yes No

Burning tongue/lips?

Yes No

Orthodontic treatment (braces?)

Yes No

Frequent blister, lips/mouth?

Yes No

Clenching/grinding?

Yes No

Sensitive teeth (hot or cold?)

Yes No

Sensitive to sweets?

Yes No

Clicking/popping jaw?

Yes No

Sensitive to biting?

Yes No

Difficulty opening or closing jaw?

Yes No

Food Impaction?

Yes No

Loose teeth?

Yes No

Biting cheeks/lips?

Yes No

Medical History

Please describe your current overall health.

Excellent Good Fair Poor

Have there been any changes in your general health in the past year?

Yes No

If yes, please describe.

Are you now under a doctor’s care for a medical condition?

Yes No

Date of last physical exam?

If yes, please describe.

Name of physician

Physician phone number

Have you ever been hospitalized or had a serious illness?

Yes No

If yes, please describe.

Have you ever had surgery?

Yes No

If yes, please describe.

Do you have, or have you ever had, any of the following conditions

Congenital heart disease, cardiovascular disease – like heart attack, heart murmur, coronary artery disease, chest pain, high/ low blood pressure, stroke, irregular heartbeat, heart surgery, pacemaker?

Yes No

Lung disease – like asthma, emphysema, COPD, chronic cough, bronchitis, pneumonia, tuberculosis, shortness of breath, chest pain, severe coughing?

Yes No

Implants placed anywhere in the body – like heart valve, pacemaker, hip, knee?

Yes No

Bleeding disorder, anemia, bleeding tendency, blood transfusion, or bruise easily?

Yes No

Kidney disease or kidney failure, requiring dialysis?

Yes No

Liver disease – like jaundice, hepatitis A, B, or C?

Yes No

Thyroid disease?

Yes No

Arthritis?

Yes No

Stomach ulcers or colitis?

Yes No

Significant weight loss or gain?

Yes No

Diabetes?

Yes No

Sinus or nasal problems?

Yes No

Glaucoma?

Yes No

Sleep apnea?

Yes No

Cancer?

Yes No

Osteoporosis or osteopenia?

Yes No

If yes, type.

Diagnosis date

Treatments

Do you have any other medical conditions that are important for your doctor to know about?

Yes No

If yes, please describe.

FAMILY MEDICAL HISTORY - Do you have a family history of any of the following conditions?

Diabetes?

Yes No

Relationship

Lung disease?

Yes No

Relationship

Cancer?

Yes No

Relationship

Heart disease?

Yes No

Relationship

Bleeding problems?

Yes No

Relationship

Has an immediate family member had any problems with local anesthesia, general anesthesia, and/or intravenous sedation?

Yes No

If yes, please describe.

MEDICATIONS – Are you currently prescribed or taking any of the following:

Antibiotics?

Yes No

Prescription pain medication?

Yes No

Anticoagulants or blood thinners?

Yes No

Aspirin or drugs such as Motrin, Aleve, Ibuprofen?

Yes No

Heart medications?

Yes No

Insulin or oral anti-diabetic drugs?

Yes No

Steroids – like cortisone or prednisone?

Yes No

Blood pressure medications?

Yes No

Antianxiety agents, antidepressants, or other psychiatric medications?

Yes No

Bisphosphonates or other medications to strengthen your bones?

Yes No

Cancer or chemotherapy drugs?

Yes No

Any other medications or supplements?

Yes No

Please list the specific medications indicated above and/or any other medications not listed above that you are currently taking. Please including all prescription medications, diet drugs, over the counter medications, herbal or holistic remedies, vitamins, or minerals:.

Add Medication and Dose

ALLERGIES – Are you allergic to or have you had an adverse reaction to:

Latex?

Yes No

Codeine or other pain control medications?

Yes No

Food or food products?

Yes No

Aspirin, ibuprofen (Motrin), or naproxen (Aleve)?

Yes No

Sedatives or barbiturates?

Yes No

Penicillin or other antibiotics?

Yes No

Any other medications?

Yes No

Any other allergies?

Yes No

If yes, please describe.

ANESTHESIA HISTORY

Have you had any problem associated with local anesthesia, general anesthesia, and/or intravenous sedation?

Yes No

If yes, please describe.

FEMALE PATIENTS

Are you pregnant?

Yes No

Is there any chance you might be pregnant?

Yes No

SOCIAL HISTORY

Have you ever smoked, vaped or chewed tobacco?

Yes No

If yes, for how long?

Have you ever sought professional care or been hospitalized for:

Substance abuse

Yes No

Emotional disorders

Yes No

Alcoholism

Yes No

Do you use:

Alcohol?

Yes No

If yes, how often per week?

Marijuana?

Yes No

If yes, how often per week?

Recreational drugs?

Yes No

If yes, how often per week?

DO YOU WISH TO TALK TO THE DOCTOR ABOUT ANYTHING IN PRIVATE?

Yes No

I understand the importance of a truthful and complete health history to assist my doctor in providing coordinated care. To the best of my knowledge, the above information is complete and correct.

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.

Signature of patient, parent, guardian

Date

Printed name of patient, parent, guardian/Relationship

For office staff use - HEALTH HISTORY REVIEW

Add Health History Review

For office staff use - ADDITIONAL CLINICAL DOCUMENTATION

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