Health History Form

Patient Name

Date

Primary reason for this dental appointment

Examination

Emergency

Consultation

Dental History

Do you have a specific dental problem?

Yes No

If yes, please describe.

Do you have dental examination on a routine basis?

Yes No

Last Visit

Do you think you have active decay or gum disease?

Yes No

Do you brush or floss on a routine basis?

Yes No

If yes, discuss.

Do your gums ever bleed?

Yes No

Discuss

Do you like your smile?

Yes No

Why?

Does food catch between your teeth?

Yes No

Any loose teeth?

Do you want to keep your remaining teeth?

Yes No

Do you ever have clicking, popping or discomfort in the joint? Do you brux or grind?

Yes No

Have your past experiences in a dental office always been positive?

Yes No

Do you smoke or chew? Any sores or growths in your mouth?

Yes No

If yes, discuss.

Name of previous dentist (optional)

Date of last full-mouth x-rays (16 small films or panoramic)

Medical History

Are you under a physician's care now?

Yes No

Why?

Who?

Phone

Have you ever been hospitalized or had a major operation?

Yes No

If yes, discuss.

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

Yes No

If yes, discuss.

Are you taking any medications, aspirin, vitamins, herbals, pills or drugs?

Yes No

If yes, what?

Are you on a special diet?

Yes No

If yes, discuss?

Are you allergic to any medications or substances?

Yes No

Please check box below

Aspirin

Penicillin

Codeine

Acrylic

Metal

Latex Rubber

Milk

Other

If other, please specify?

Women: Please check

Pregnant/trying to get pregnant

Nursing

Taking oral contraceptives

Discuss

Do you now have or have you ever had any of the following? Do you take any of these medicines? Please check appropriate boxes.

*If yes to any of the starred conditions please call prior to your appointment... premedication or changes in medication may be required.

Heart Disease/Surgery

Yes No

Excessive Bleeding

Yes No

Chemotherapy

Yes No

Heart Murmur or Defect

Yes No

Sickle Cell Disease

Yes No

Osteoporosis

Yes No

Irregular Heart Beat

Yes No

Hemophilia

Yes No

Bisphosphonates

Yes No

Angina/Chest Pain

Yes No

Methemoglobinemia

Yes No

Osteonecrosis of Jaw

Yes No

Heart Attack/ Failure

Yes No

Leukemia

Yes No

Aredia I.V. Reclast I.V.

Yes No

Congenital Heart Disorder

Yes No

Recent Blood Transfusion

Yes No

Zometa I.V.

Yes No

Mitral Valve Prolapse

Yes No

Swelling of Limbs

Yes No

Fosamax, Actonel, Boniva

Yes No

Scarlet Fever

Yes No

Lung Disease

Yes No

Stomach/Intestinal Disease

Yes No

Rheumatic Fever

Yes No

Breathing Problems

Yes No

Ulcers

Yes No

Artificial Heart Valve

Yes No

Shortness of Breath

Yes No

Recent Weight Loss

Yes No

Heart Pace Maker

Yes No

Frequent Cough

Yes No

Frequent Diarrhea

Yes No

Pulmonary Shunt

Yes No

Hay Fever

Yes No

Diabetes

Yes No

High Blood Pressure

Yes No

Sinus Trouble

Yes No

Excessive Thirst

Yes No

Low Blood Pressure

Yes No

Asthma

Yes No

Hypoglycemia

Yes No

Bacterial Endocarditis

Yes No

Bloody Sputum

Yes No

Liver Disease

Yes No

Unexplained Fever

Yes No

Emphysema

Yes No

Hepatitis A (Infectious)

Yes No

Bruise Easily/Blood Disease

Yes No

Tuberculosis

Yes No

Hepatitis B or C

Yes No

Anemia

Yes No

Cancer

Yes No

Protease Inhibitor

Yes No

Coronary Stent

Yes No

X-Ray Treatments (Radiation)

Yes No

Night Sweats

Yes No

Yellow Jaundice

Yes No

Kidney Problems

Yes No

Renal Dialysis

Yes No

Thyroid Disease

Yes No

Parathyroid Disease

Yes No

Arthritis/Gout

Yes No

Rheumatism

Yes No

Pain in Jaw Joints

Yes No

Cortisone Medicine

Yes No

Artificial Joint

Yes No

Sexually Transmitted Disease

Yes No

AIDS

Yes No

HIV Positive

Yes No

Genital Herpes

Yes No

Drug Addiction/Alcoholism

Yes No

Tattoos/Body Piercing

Yes No

Sleep Apnea

Yes No

Cold Sores

Yes No

Fever Blisters

Yes No

Herpes

Yes No

Stroke

Yes No

Convulsions

Yes No

Epilepsy or Seizures

Yes No

Fainting or Dizziness

Yes No

Glaucoma

Yes No

Tumors or Growths

Yes No

Nervousness

Yes No

Psychiatric Care

Yes No

Alzheimer's Disease

Yes No

Allergies (Medicines)

Yes No

Allergies (Pollen/Dust)

Yes No

Hives or Rash

Yes No

Need Pre-medication?

Yes No

Ever taken fen-phen?

Yes No

Cochlear Implants?

Yes No

Have you ever had any other serious illness not checked above?

Yes No

If yes, please discuss.

Do you wish to talk to the dentist privately about any problem?

Yes No

To the best of my knowledge, all the preceding answers are correct. If I have any changes in my health status or if my medicines change, I shall inform the dentist and staff at the next appointment without fail.

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.

Patient Signature (Parent or Guardian)

Date

Reviewed by Doctor

Date

Pulse

History Review and Significant Findings

Medical Updates

I have read my MEDICAL HISTORY dated

and confirm that it adequately states past and present conditions.

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