Health History Form

For Office Use Only

Chart #

Response Date

Patient Information

Last Name

First Name

Preferred Name

Title

Gender

Male Female

Family Status

Married Single Child Other

Date of Birth

Prev. Visit

Email Address

Home Phone

Mobile Phone

Work Phone

Best Time to Call

Address

City

State

Zip

SSN

Please list below any Emergency Contacts:

Name

Phone Number

Relationship

Add Another Emergency Contact

Primary Physician

Phone Number

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

I hereby allow Freeman Dental PLLC to release protected health information to the entities or family members below:

Name

Phone Number

Relationship

Add Another Entity/Family Member

Whom may we thank for referring you to our practice?

Commercial

Internet

Other (please name)

Medical History

Please List below any current medication you are taking, including vitamins, natural or herbal supplements, dietary supplements, and any over the counter medications.

Please check if any apply:

Active Tuberculosis?

Cough that produces blood?

None of these apply

Persistant cough greater than a 3 week duration?

Been exposed to anyone with Tuberculosis?

Are you taking or scheduled to begin taking an antiresorptive agent ( like Fosomax, Actonel, Atelvia, Boniva, Reclast, Prolia ) for osteoporosis or Paget's disease?

Yes No

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 skelatal complications resulting from Paget's disease, multiple myeloma or metastic cancer?

Yes No

When is the date treatment began?

Do you take antibotic premedication for your dental visits?

Yes No

Name of physician and their specialty:

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

Yes No

What joint was replaced? What date was the joint replaced? Have you had any complications?

Please mark any that apply with a checkbox. Except for the conditions listed below, antibiotic prophylaxis is no longer recommended for any other form of congenital heart disease.

Artificial (prosthetic) heart valve

Congenital Heart Disease (CHD)

Repaired CHD with residual defects

Previous infective endocarditis

Unrepaired cyanotic CHD

NONE OF THESE APPLY

Damaged valves in transplanted heart

Repaired (completely) in last 6 months

If any condition or alert selected above needs further clarification, please explain below:

Describe any current medical treatment, impending surgery, or other treatment that may possibly affect your dental treatment:

By checking this box, I acknowledge the above information is correct and I understand it is my responsibility to inform the office of any changes in my health as soon as possible.

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

Signature

Date

Dental History

Previous Dentist name and how long have you been a patient there:

Date of most recent dental exam and x-rays:

What is your immediate concern?

Are you fearful of dental treatment? How fearful, on a scale of 1 (least) to 10(most)

Personal History, Check all that apply:

Had complications from past dental treatment

Had / Have braces, orthodontic treatment

Do you drink bottle water or filtered water

Smile Characteristics, Check all that apply:

Is there anything about the apperance of your teeth that you would like to change?

Have you ever whitened (bleached) your teeth?

Have you felt uncomfortable or self conscious about the appearance of your teeth?

Have you been disappointed with the appearance of previous dental work?

Bite and Jaw Joint, Check all that apply:

You have problems with your jaw joint

You clench your teeth in the daytime or make them sore

You have problems with crowding or developing spaces

You wear or have worn a bite appliance

Tooth structure, Check all that apply:

Do you have dry mouth

Any teeth sensitive to hot, cold, sweets, or you avoid brushing any part of your mouth

Food gets caught between any teeth

Are you currently experiencing dental pain or discomfort

Do you have sores or ulcers in your mouth

Are you interested?

Botox

Teeth Whitening

Invisalign

Sedation

If any of the checked boxes need further explanation, please describe:

By checking this box, I acknowledge the above information is correct and I understand it is my responsibility to inform the office of any changes in my health as soon as possible.

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

Signature

Date

Your information will be encrypted.