boulevard-dental.com - Health History Form

Health History
Select Location *

Seminole Clearwater
Location and Name
Title *
HIPAA Authorization Person
Name *

First Name Last Name
Date of Birth *

Day Month Year
Gender *
If minor name of parent
Residence Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Social Security No
Cell Phone Number *
Please enter a valid phone number.
Home Phone Number
Please enter a valid phone number.
Business Phone Number
Please enter a valid phone number.
Ext
Email Address *
example@example.com
Employed By
Referred By
Name of spouse

First Name Last Name
Spouse Work Phone Number
Please enter a valid phone number.
Ext
Dental Insurance Carrier
Policy No
S.S. # of Primary Insurance Holder
Date of Birth

Day Month Year
Emergency Contact
Name *
Emergency Contact Number *
Please enter a valid phone number.
EXT
Are you interested in straightening your teeth? *

Yes No
Are you having any discomfort at this time *

Yes No
How long since you have been to a dentist
What was done then
Are your teeth sensitive to heat? *

Yes No
Are your teeth sensitive to cold? *

Yes No
How often do you brush your teeth?
How often do you Floss your teeth?
Does food wedge between your teeth? *

Yes No
Where? *
Are you interested in whitening your teeth? *

Yes No
Do you grind or clench your teeth? *

Yes No
When? *
Have you ever had gum treatments? *

Yes No
When? *
Any pain in or around your ears? *

Yes No
Do you hear popping clicking or snapping noises when you chew *

Yes No
Do you have frequent headaches? *

Yes No
Are you aware of any swelling or lump in your mouth? *

Yes No
Your Medical History
Physician’s Name

First Name Last Name
Date of last physical exam

Month Day Year
Do you have or had any of the following?
Do you wear a pacemaker?

Yes No
Date

Month Day Year
Any heart problems

Yes No
Any heart surgery *

Yes No
Date

Month Day Year
High/Low blood pressure *

Yes No
MS *

Yes No
Circulatory problems *

Yes No
Nervous problems *

Yes No
Radiation treatments / Chemo *

Yes No
Stroke *

Yes No
Heart Murmur *

Yes No
History of Bisphosphonates (Fosamax) *

Yes No
Seizures or convulsions *

Yes No
Prolonged bleeding / blood thinners *

Yes No
Thyroid condition *

Yes No
Allergies to anesthetics *

Yes No
Are you allergic to latex? *

Yes No
Allergies to medicines or drugs *

Yes No
Are you pregnant? *

Yes No
Anemia *

Yes No
Asthma *

Yes No
Arthritis *

Yes No
Artificial Joints / Heart Valves

Yes No
Date

Month Day Year
Do you snore? *

Yes No
Diabetes *

Yes No
Hepatitis *

Yes No
Type *
Malignancies *

Yes No
Rheumatic Fever *

Yes No
Lupus *

Yes No
Tuberculosis *

Yes No
Ulcer *

Yes No
AIDS / HIV Positive *

Yes No
Birth control pills *

Yes No
Do you feel tired/sleepy? *

Yes No
Other

Yes No
Explain
List all medications you are currently taking
What medications are you allergic to
What surgeries have you had or are planning on having
*

I, the undersigned, agree to guarantee payment of all amounts owed by the patient now or in the future in consideration of the treatment to be provided by Drs. Wujick, Kopakin, Moss, or Castillo. All court fees, attorney’s fees, or other fees necessary to collect this account are payable by me
Your Signature *

Clear
Patient Name *

First Name Last Name
Date *

Month Day Year
Should be Empty:

Health History

Emergency Contact

Your Medical History

Do you have or had any of the following?