Health History Form

As required by law, our office adheres to written policies and procedures to protect the privacy of information about you that we create, receive or maintain. Your answers are for our records only and will be kept confidential subject to applicable laws. Please note that you will be asked some questions about your responses to this questionnaire and there may be additional questions concerning your health. This information is vital to allow us to provide appropriate care for you. This office does not use this information to discriminate.

Today's Date

Name

Last

First

Middle

Home Phone

Include area code

Business/Cell Phone

Include area code

Address

Mailing Address

City

State

Zip

Occupation

Height

Weight

Date of Birth

Sex

SS# or Patient ID

Emergency Contact

Relationship

Home Phone

Include area code

Cell Phone

Include area code

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

Your Name

Relationship

Do you have any of the following diseases or problems: (Check DK if you Don't Know the answer to the question.)

Active Tuberculosis

Yes No DK

Persistent cough greater than a 3 week duration

Yes No DK

Cough that produces blood

Yes No DK

Been exposed to anyone with tuberculosis

Yes No DK

If you answer yes to any of the 4 items above, please stop and return this form to the receptionist.

Dental Information

Please mark (X) your responses to the following questions.

Do your gums bleed when you brush or floss?

Yes No DK

Are your teeth sensitive to cold, hot, sweets or pressure?

Yes No DK

Is your mouth dry?

Yes No DK

Have you had any periodontal (gum) treatments?

Yes No DK

Have you ever had orthodontic (braces) treatment?

Yes No DK

Have you had any problems associated with previous dental treatment?

Yes No DK

Is your home water supply fluoridated?

Yes No DK

Do you drink bottled or filtered water?

Yes No DK

If yes, how often? (Check one:)

Daily

Weekly

Ocassionally

Are you currently experiencing dental pain or discomfort?

Yes No DK

Do you have earaches or neck pains?

Yes No DK

Do you have any clicking, popping or discomfort in the jaw?

Yes No DK

Do you brux or grind your teeth?

Yes No DK

Do you have sores or ulcers in your mouth?

Yes No DK

Do you wear dentures or partials?

Yes No DK

Do you participate in active recreational activities?

Yes No DK

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

Yes No DK

Date of your last dental exam

What was done at that time?

Date of last dental x-rays

What is the reason for your dental visit today?

How do you feel about your smile?

Medical Information

Please mark (X) your response to indicate if you have or have not had any of the following diseases or problems

Are you now under the care of a physician?

Yes No DK

Physician Name

Phone

Include area code

Address

City

State

Zip

Are you in good health?

Yes No DK

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

Yes No DK

If yes, what condition is being treated?

Date of last physical exam

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

Yes No DK

If yes, what was the illness or problem?

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

Yes No DK

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

Do you wear contact lenses?

Yes No DK

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

Yes No DK

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?

Yes No DK

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?

Yes No DK

Date Treatment began

Do you use controlled substances (drugs)?

Yes No DK

Do you use tobacco (smoking, snuff, chew, bidis)?

Yes No DK

If so, how interested are you in stopping? Check One

Very

Somewhat

Not Interested

Do you drink alcoholic beverages?

Yes No DK

If yes, how much alcohol did you drink in the last 24 hours?

If yes, how much do you typically drink in a week?

WOMEN ONLY Are you:

Pregnant?

Yes No DK

Number of weeks

Taking birth control pills or hormonal replacement?

Yes No DK

Nursing?

Yes No DK

Allergies. Are you allergic to or have you had a reaction to:

To all yes responses, specify type of reaction.

Local anesthetics

Yes No DK

Reaction

Aspirin

Yes No DK

Reaction

Penicillin or other antibiotics

Yes No DK

Reaction

Barbiturates, sedatives, or sleeping pills

Yes No DK

Reaction

Sulfa drugs

Yes No DK

Reaction

Codeine or other narcotics

Yes No DK

Reaction

Metals

Yes No DK

Reaction

Latex (rubber)

Yes No DK

Reaction

Iodine

Yes No DK

Reaction

Hay fever/seasonal

Yes No DK

Reaction

Animals

Yes No DK

Reaction

Food

Yes No DK

Reaction

Other

Yes No DK

Reaction

Please mark (X) your response to indicate if you have or have not had any of the following diseases or problems.

Artificial (prosthetic) heart valve

Yes No DK

Previous infective endocarditis

Yes No DK

Damaged valves in transplanted heart

Yes No DK

Congenital heart disease (CHD)

Unrepaired, cyanotic CHD

Yes No DK

Repaired (completely) in last 6 months

Yes No DK

Repaired CHD with residual defects

Yes No DK

Except for the conditions listed above, antibiotic prophylaxis is no longer recommended for any other form of CHD

Cardiovascular disease

Yes No DK

Angina

Yes No DK

Arteriosclerosis

Yes No DK

Congestive heart failure

Yes No DK

Damaged heart valves

Yes No DK

Heart attack

Yes No DK

Heart murmur

Yes No DK

Low blood pressure

Yes No DK

High blood pressure

Yes No DK

Other congenital heart defects

Yes No DK

Mitral valve prolapse

Yes No DK

Pacemaker

Yes No DK

Rheumatic fever

Yes No DK

Rheumatic heart disease

Yes No DK

Abnormal bleeding

Yes No DK

Anemia

Yes No DK

Blood transfusion

Yes No DK

If yes, date.

Hemophilia

Yes No DK

AIDS or HIV infection

Yes No DK

Arthritis

Yes No DK

Autoimmune disease

Yes No DK

Rheumatoid arthritis

Yes No DK

Systemic lupus erythematosus

Yes No DK

Asthma

Yes No DK

Bronchitis

Yes No DK

Emphysema

Yes No DK

Sinus Trouble

Yes No DK

Tuberculosis

Yes No DK

Cancer/Chemotherapy/ Radiation Treatment

Yes No DK

Chest pain upon exertion

Yes No DK

Chronic pain

Yes No DK

Diabetes: Type I

Yes No DK

Diabetes: Type II

Yes No DK

Eating disorder

Yes No DK

Malnutrition

Yes No DK

Gastrointestinal disease

Yes No DK

G.E. Reflux/persistent heartburn

Yes No DK

Ulcers

Yes No DK

Thyroid problems

Yes No DK

Stroke

Yes No DK

Glaucoma

Yes No DK

Hepatitis, jaundice or liver disease

Yes No DK

Epilepsy

Yes No DK

Fainting spells or seizures

Yes No DK

Sleep disorder

Yes No DK

Neurological disorders

Yes No DK

If yes, specify.

Do you snore?

Yes No DK

Kidney problems

Yes No DK

Mental health disorders

Yes No DK

If yes, specify.

Recurrent Infections

Yes No DK

Type of Infection

Night sweats

Yes No DK

Osteoporosis

Yes No DK

Persistent swollen glands in neck

Yes No DK

Severe headaches/ migraines

Yes No DK

Severe or rapid weight loss

Yes No DK

Sexually transmitted disease

Yes No DK

Excessive urination

Yes No DK

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

Yes No DK

Name of physician or dentist making recommendation

Phone

Include area code

Do you have any disease, condition, or problem not listed above that you think I should know about?

Yes No DK

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

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/Legal Guardian

Date

Signature of Dentist

Date

FOR COMPLETION BY DENTIST

Comments

Your information will be encrypted.