boulevard-dental.com - Health History Form

Health History
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.Format: (000) 000-0000.
Home Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Business Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
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.Format: (000) 000-0000.
Ext
Dental Insurance Carrier
Policy No
S.S. # of Primary Insurance Holder
Date of Birth

DayMonthYear
Emergency Contact
Name*
Emergency Contact Number*
Please enter a valid phone number.Format: (000) 000-0000.
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
Your Medical History
Physician’s Name

First NameLast Name
Date of last physical exam

MonthDayYear
Do you have or had any of the following?
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
Should be Empty:

Health History

Emergency Contact

Your Medical History

Do you have or had any of the following?