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

Women
18. Are you pregnant? YesNo
19. Do you have any problems associated with you menstrual period? YesNo
20. Are you nursing? YesNo
   
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.