health_history_form

Patient Name
Date of Birth

MonthDayYear
Date
1. Is your general health good?
If No, Explain:
2. Has there been a change in your health within the last year?
If YES, explain:
3. Have you gone to the hospital or emergency room or had a serious illness in the last three years?
If YES, explain
4. Are you being treated by a physician now?
If YES, explain
Date of last medical exam?

MonthDayYear
Date
Reason for exam
5. Have you had problems with prior dental treatment?
If YES, explain
Date of last dental exam

MonthDayYear
Date
Name of last treating dentist
6. Are you in pain now?
If YES, explain
HAVE YOU EVER EXPERIENCED ANY OF THE FOLLOWING?
Chest Pain (angina)
Blood in stools
Frequest Vomitting
Fainting spells
Diarrhea or constipation
Jaundice
Recent significant weight loss
Frequent Urination
Dry mouth
Fever
Difficulty urinating
Excessive Thirst
Night Sweats
Ringing in ears
Difficulty swallowing
Persistent cough
Headache
Swollen ankles
Coughing up blood
Dizziness
Joint pain or stiffness
Bleeding problems
Blurred vision
Shortness of breath
Blood in urine
Bruise easily
Sinus problems
Others
HAVE YOU EVER HAD OR DO YOU HAVE ANY OF THE FOLLOWING?
Heart disease
AIDS/HIV
Psychiatric care
Family history of heart disease
Surgeries
Osteoporosis
Heart attack
Hospitalization
Thyroid disease
Artificial joint
Diabetes
Asthma
Stomach problems or ulcers
Family history of diabetes
Hepatitis
Heart defects
Tumors or cancer
Sexual transmitted disease
Heart murmurs
Chemotherapy
Herpes
Rheumatic fever
Radiation
Canker or cold sores
Skin disease
Athritis, theumatism
Anemia
Hardening of arteries
Emphysema or other lung disease
Liver disease
High blood pressure
Kidney or bladder disease
Eye disease
Seizures
Stroke
Transplants
Cosmetic surgery
Eating disorders
Tuberculosis
Others
ARE YOU ALLERGIC TO OR HAVE YOU HAD A REACTION TO ANY OF THE FOLLOWING?
Aspirin
Valium or other sedatives
Codeine or other narcotics
Penicillin or other antibiotics
Latex
Food
Nitrous oxide
Local anesthetic
Metal
Others
ARE YOU TAKING OR HAVE YOU TAKEN ANY OF THE FOLLOWING IN THE LAST THREE MONTHS?
Recreational drugs
Tobacco in any form
Antibiotics
Over the counter medicines
Alcohol
Supplements
Weight loss medications
Bisphosphonate(Fosamax)
Aspirin
Antidepressant
Herbal supplements
Please list all prescription medications
WOMEN ONLY(Please check Yes or No for each)
Are you or could you be pregnant?
Are you or could you be pregnant? If YES, what month?
Are you nursing?
Are you taking birth control pills?
All patients (Please check Yes or No for each)
Do you have or have you had any other diseases or medical problems NOT listed on this form?
If YES, please explain:
Have you ever been pre-medicated for dental treatment??
If YES, why
Have you ever taken Fen-Phen?
If YES, when
Is there any issue or condition that you would like to discuss with the dentist in private?
The practice of dentistry involves treating the whole person. If the dentist determines that there may be a potentially medically compromised situation, medical consultation may be needed prior to commencement of dental treatment.

I authorize the dentist to contact my physician.
Patient’s Signature
Date

MonthDayYear
Date
Physician’s Name
Phone Number
Format: (000) 000-0000.
Whom would you like us to contact in case of an emergency?
Name
Relationship
Phone Number
Format: (000) 000-0000.
Signature of Patient (Parent or Guardian)
I certify that I have read and understand this form. To the best of my knowledge, I have answered every question completely and accurately. I will inform my dentist of any change in my health and/or medication. Further, 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.
Date

MonthDayYear
Date
MEDICAL UPDATES

I have reviewed my Health History and confirm that it accurately states past and present conditions.

Rows	DATE	PATIENT SIGNATURE	CHANGES TO HEALTH HISTORY	DENTIST INITIALS

Should be Empty:

HAVE YOU EVER EXPERIENCED ANY OF THE FOLLOWING?

HAVE YOU EVER HAD OR DO YOU HAVE ANY OF THE FOLLOWING?

ARE YOU ALLERGIC TO OR HAVE YOU HAD A REACTION TO ANY OF THE FOLLOWING?

ARE YOU TAKING OR HAVE YOU TAKEN ANY OF THE FOLLOWING IN THE LAST THREE MONTHS?

WOMEN ONLY(Please check Yes or No for each)

All patients (Please check Yes or No for each)

MEDICAL UPDATES