Health History Form

Patient's Name

Date

Reason for today's visit

Former Dentist

City / State

Date of last dental visit

Date of last dental X-rays

How often do you floss?

How often do you brush?

Physician's Name

Date of last visit

Due Date

List any medications you are currently taking and the correlating diagnosis:

Pharmacy Name

Phone No.

Aspirin

Barbiturates (Sleeping pills)

Codeine

Iodine

Latex

Local Anesthetic

Penicillin

Sulfa

Other

If other, Please specify

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