boulevard-dental.com - Health History Form

Select Location*

SeminoleClearwater

Location and Name

Title*

HIPAA Authorization Person

Name*

First NameLast Name

Date of Birth*

DayMonthYear

Gender*

If minor name of parent

Residence Address

Street Address

Street Address Line 2

CityState / 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 NameLast 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

DayMonthYear

Name*

Emergency Contact Number*

Please enter a valid phone number.

EXT

Are you interested in straightening your teeth?*

YesNo

Are you having any discomfort at this time*

YesNo

How long since you have been to a dentist

What was done then

Are your teeth sensitive to heat?*

YesNo

Are your teeth sensitive to cold?*

YesNo

How often do you brush your teeth?

How often do you Floss your teeth?

Does food wedge between your teeth?*

YesNo

Where?*

Are you interested in whitening your teeth?*

YesNo

Do you grind or clench your teeth?*

YesNo

When?*

Have you ever had gum treatments?*

YesNo

When?*

Any pain in or around your ears?*

YesNo

Do you hear popping clicking or snapping noises when you chew*

YesNo

Do you have frequent headaches?*

YesNo

Are you aware of any swelling or lump in your mouth?*

YesNo

Physician’s Name

First NameLast Name

Date of last physical exam

MonthDayYear

Do you wear a pacemaker?

YesNo

Date

MonthDayYear

Any heart problems

YesNo

Any heart surgery*

YesNo

Date

MonthDayYear

High/Low blood pressure*

YesNo

MS*

YesNo

Circulatory problems*

YesNo

Nervous problems*

YesNo

Radiation treatments / Chemo*

YesNo

Stroke*

YesNo

Heart Murmur*

YesNo

History of Bisphosphonates (Fosamax)*

YesNo

Seizures or convulsions*

YesNo

Prolonged bleeding / blood thinners*

YesNo

Thyroid condition*

YesNo

Allergies to anesthetics*

YesNo

Are you allergic to latex?*

YesNo

Allergies to medicines or drugs*

YesNo

Are you pregnant?*

YesNo

Anemia*

YesNo

Asthma*

YesNo

Arthritis*

YesNo

Artificial Joints / Heart Valves

YesNo

Date

MonthDayYear

Do you snore?*

YesNo

Diabetes*

YesNo

Hepatitis*

YesNo

Type*

Malignancies*

YesNo

Rheumatic Fever*

YesNo

Lupus*

YesNo

Tuberculosis*

YesNo

Ulcer*

YesNo

AIDS / HIV Positive*

YesNo

Birth control pills*

YesNo

Do you feel tired/sleepy?*

YesNo

Other

YesNo

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*

Patient Name*

First NameLast Name

Date*

MonthDayYear

Health History

Emergency Contact

Your Medical History

Do you have or had any of the following?