Health History Form

Please fill out the form below or Print the form prior to your first visit.

Click here to download, print and fill out
the health history form.

 

Name:
Address
City
State
Zip Code
Home Phone
Work Phone
Mobile Phone
Email
Date of Birth
Sex
Civil Status:
Name of Spouse
Occupation
Closest Relative
Phone
   
Are completing this form with another person?  Yes No
What is your relationship with this person?
Referred by:
   
In the following questions, please click yes or no. Your answers are confidential and for our records only.
 
1. Are you in good health?  Yes No
2. Has there been any change in your general health in the past year?  Yes No
3. My last physical exam was on  Yes No
4. Are you now under the care of a physician?  Yes No
If so, what is the condition that is being treated?
5. The name, phone and address of your physician is
6. Have you had any serious illness or operation?  Yes No
If so, what was the illness or operation?
7. Have you been hospitalized or had any serious illness within the past five (5) years?  Yes No
8. Do you have or have you had any of the following diseases or conditions?
• Damage heart valves or artificial heart valves, including heart murmur  Yes No
• Congenital heart lesions  Yes No
• Cardiovascular disease (heart problem, heart attack, coronary insufficiency,
coronary occlusion, high blood pressure, arteriosclerosis, stroke)		  Yes No
• Do you have pain in chest upon exertion?  Yes No
• Are you ever short of breath after mild exercise?  Yes No
• Do your ankles swell?  Yes No
• Do you get short of breath when you lie down?  Yes No
• Do you require extra pillows when you sleep?  Yes No
• Do you have a cardiac pacemaker?  Yes No
• Allergy  Yes No
• Sinus Trouble  Yes No
• Asthma or have fever  Yes No
• Hives or skin rash  Yes No
• Fainting spells or seizures  Yes No
• Diabetes  Yes No
• Do you have to urinate (pass water) more than six times a day?  Yes No
• Are you thirsty much of the time?  Yes No
• Does your mouth frequently become dry?  Yes No
• Hepatitis, jaundice or liver disease  Yes No
• Arthritis  Yes No
• Inflammatory rheumatism (painful swollen joints)  Yes No
• Stomach ulcers  Yes No
• Kidney trouble  Yes No
• Tuberculosis  Yes No
• Do you have a persistent cough or cough up blood?  Yes No
• Low blood pressure  Yes No
• Venereal disease  Yes No
• Epilepsy  Yes No
• Psychiatric problems  Yes No
• Cancer  Yes No
• AIDS or other immunosuppressive disorders  Yes No
• Other
• Have you had abdominal bleeding associated with previous extractions,
surgery, or trauma?		  Yes No
• Do you bruise easily?  Yes No
• Have you ever required a blood transfusion?  Yes No
If so, explain the circumstances
• Do you have any blood disorder such as anemia?  Yes No
• Have you had surgery, x-ray or drug treatment for tumor, growth,
or other head or neck condition?		  Yes No
• Are you taking any drug or medicine?  Yes No
If so, what are you taking?
9. Are you taking any of the following?
• Antibiotics or sulfa drugs  Yes No
• Anticoagulants (blood thinners)  Yes No
• Medicine for high blood pressure  Yes No
• Cortisone (steroids)  Yes No
• Tranquilizers  Yes No
• Antihistamines  Yes No
• Aspirin  Yes No
• Insulin, tolbutamide (Orinase) or similar drug Yes No  Yes No
• Digitalis or drugs for heart trouble  Yes No
• Nitroglycerin  Yes No
• Oral contraceptive or other hormonal therapy  Yes No
• Other
10. Are you allergic or have you reacted adversely to:
• Local anesthetics  Yes No
• Penicillin or other antibiotics  Yes No
• Sulfa drugs  Yes No
• Barbiturates, sedatives, or sleeping peels  Yes No
• Aspirin  Yes No
• Iodine  Yes No
• Codeine or other narcotics  Yes No
• Other
11. Have you had any serious trouble associated with any previous dental treatment?  Yes No
If so, explain
12. Do you have any disease, condition, or problem not listed above
that you think I should know about?		  Yes No
If so, explain
13. Are you employed in any situation which exposes you regularly
to x-rays or other ionizing radiation?		  Yes No
14. Are you wearing contact lenses?  Yes No
15. Have you had anything to eat or drink in the last 4 hours?  Yes No
16. Are you wearing removable dental appliances?  Yes No
   

Women
18. Are you pregnant?  Yes No
19. Do you have any problems associated with you menstrual period?  Yes No
20. Are you nursing?  Yes No
   
Chief Dental Complaint  
I certify that I have read and understand the above. I acknowledge that my questions, if any, about the 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 errors or omissions that I may have made in the completion of this form.