Confidential Health History

Patient Name

Date of Birth

Date

Address

Street Address

Street Address Line 2

CityState

Zip Code

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email

example@example.com

Is your general health good?

If NO, explain

Has there been a change in your health within the last 3 years?

If YES, explain

Have you been admitted to the hospital or emergency room or had a serious illness in the last three years? If yes, please explain.

Date of last medical exam?

Date

Are you currently experiencing dental pain?

If YES, explain

HAVE YOU EVER EXPERIENCED OR ARE CURRENTLY EXPERIENCING ANY OF THE FOLLOWING?

Rows	Yes	No
Angina or chest pain
Fainting Spells
Recent significant weight loss
Dry mouth
Difficulty swallowing
Dizziness or vertigo
Bleeding problems
Bruise easily
Artificial heart valve
Headaches more than once a week
Recent surgery
Osteoporosis
Heart attack
Thyroid disease
Diabetes
Artificial joint
Asthma
Cancer or tumors
Anxiety
Depression
Hepatitis
Heart murmur
Radiation or chemotherapy
Anemia
Sleep apnea
High blood pressure
Stroke
Frequent vomiting
Kidney or bladder disease
Eating disorder
Organ transplant
HIV/AIDS
Seizures or Epilepsy
Dental phobic

Do you require antibiotic premedication prior to dental treatment?

Please list any health conditions you have that weren't mentioned above

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

Do you have any allergies not listed above?

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

FOR WOMEN ONLY:

Please list all prescription medications you're currently taking OR bring a printed list with you to your appointment.

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.

Physician's Name

Phone Number

Format: (000) 000-0000.

Whom would you like us to contact in case of an emergency?

Name Phone Number Relationship to patient

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.

If necessary, I authorize the dentist to contact my physician.

Signature of Patient (Parent or Guardian)

Date