Language
English (US)
Español
Dental Health History 2020
The Dental Health History Form must be completed prior to scheduling a dental appointment and is required to be updated every 3 years.
Name
*
First Name
Last Name
Email
*
example@example.com
Date of Birth
*
-
Month
-
Day
Year
Date
Medical Information
Are you under the care of a medical physician?
*
Yes
No
What is your medical physicians name?
What is your medical physicians phone number?
Females: Could you be or are you pregnant?
*
Yes
No
Do you use controlled substances (drugs)?
*
Yes
No
Do you currently use tobacco (smoking, snuff, chew, bidis, vape)?
*
Yes
No
How long have you been using tobacco?
Smoking, snuff, chew, bidis, vaping, etc
Have you used tobacco in the past (smoking, snuff, chew, bidis, vape)?
*
Yes
No
Have you had an orthopedic total joint (hip, knee, elbow, finger) replacement?
*
Yes
No
Are you taking or scheduled to begin taking either of the medications Alendronate (Fosamax®) or Risedronate (Actonel®) for Osteoporasis or Paget’s Disease?
*
Yes
No
Since 2001, were you treated or are you presently scheduled to begin treatment with the intravenous bisphosphonates (Aredia® or Zometa®) for bone pain, hypercalcemia or skeletal complications resulting from Paget’s Disease, multiple myeloma or metastatic cancer?
*
Yes
No
Date treatment began?
-
Month
-
Day
Year
Date
Active Tuberculosis?
*
Yes
No
Persistent Cough greater than a three (3) weeks duration or Cough that produces blood?
*
Yes
No
Have you had a serious illness, operation or been hospitalized in the past five (5) years?
*
Yes
No
Are you taking or have you recently taken any prescription or over-the-counter medicine(s)?
*
Yes
No
Please list all medicines:
*
Including aspirin, vitamins, natural or herbal preparations and/or diet supplements
Have you ever had an allergic reaction to local anesthetic?
*
Yes
No
List all ALLERGIES
*
Examples: (Penicillin, latex, codeine)
History of Present Illness
Please select yes or no on the following questions
Anemia
*
Yes
No
Alcohol Use
*
Yes
No
Aneurysm
*
Yes
No
Angina/Chest Pain
*
Yes
No
GERD/Chronic Heartburn
*
Yes
No
Pacemaker
*
Yes
No
Artificial Heart Valve
*
Yes
No
Previous infective Endocarditis
*
Yes
No
Damaged Valves in transplanted heart
*
Yes
No
Congenital Heart Disease
*
Yes
No
Cyanotic CHD
Unrepaired
Repaired in last six months
Repaired with residual defects
Hemophilia
*
Yes
No
Asthma
*
Yes
No
Blood Disease
*
Yes
No
Cancer
*
Yes
No
Coumadin
*
Yes
No
Diabetes
*
Yes
No
STD/Venereal Disease
*
Yes
No
Eating Disorder
*
Yes
No
Emotional Problems
*
Yes
No
Emphysema
*
Yes
No
Epilepsy/Seizure
*
Yes
No
Fibromyalgia
*
Yes
No
Hepatitis
*
Yes
No
What type of Hepatitis do you have?
Herpes/Cold Sore
*
Yes
No
High Blood Pressure
*
Yes
No
HIV/AIDS
*
Yes
No
Heart Murmur
*
Yes
No
Mitral Valve Prolapse
*
Yes
No
Organ Transplant
*
Yes
No
Pancreatitis
*
Yes
No
Pneumonia
*
Yes
No
Respiratory Problems
*
Yes
No
Rheumatic Fever
*
Yes
No
Skin Problem/Rash
*
Yes
No
Stomach/Intestinal Problems
*
Yes
No
Stroke
*
Yes
No
Surgery
*
Yes
No
Thyroid Disease
*
Yes
No
Thyroid Disease
*
Yes
No
Glaucoma
*
Yes
No
Sleep Disorder
*
Yes
No
Hospitalization
*
Yes
No
Kidney Problems
*
Yes
No
Liver Problems
*
Yes
No
Has a physician or previous dentist recommended that you take antibiotics prior to your dental treatment?
*
Yes
No
Name of physician or dentist making this recommendation?
*
Phone number
Dental Information
Do your gums bleed when you brush/floss?
*
Yes
No
Are your teeth sensitive to cold, hot, sweets or pressure?
*
Yes
No
Does food or floss catch between your teeth?
*
Yes
No
Is your mouth dry?
*
Yes
No
Have you had any periodontal (gum) treatments?
*
Yes
No
Have you ever had orthodontic (braces) treatments?
*
Yes
No
Do you have earaches or neck pain?
*
Yes
No
Are you currently experiencing dental pain or discomfort?
*
Yes
No
Do you have sores or ulcers in your mouth?
*
Yes
No
Date of your last dental exam
*
What was done at that time?
*
Date of last dental x-rays
*
What is the reason for your dental visit today?
*
How do you feel about your smile?
*
Signature
To the best of my knowledge the above information is true and correct. I understand this information will be kept confidential. I will inform the doctor of any changes in my health and medical condition, or if my medicines change.
Signature
*
Preview PDF
Submit
Should be Empty: