Health History

  • Health History

  • As required by law, our office adheres to written policies and procedures to protect the privacy of information about you that we create, receive or maintain. Your answers are for our records only and will be kept confidential subject to applicable laws. Please note that you will be asked some questions about your responses to this questionnaire and there may be additional questions concerning your health. This information is vital to allow us to provide appropriate care for you. This office does not use this information to discriminate.

  • Sex:
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  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • If you are completing this form for another person, what is your relationship to that person?

  • Rows

  • If you answer yes to any of the 4 items above, please stop and return this form to the receptionist.

  • Dental Information

  • Rows
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  • Medical Information

    Please mark (X) your response to indicate if you have or have not had any of the following diseases or problems.
  • Are you now under the care of a physician?
  • Format: (000) 000-0000.
  • Are you in good health?
  • Has there been any change in your general health within the past year?
  • Have you had a serious illness, operation or been hospitalized in the past 5 years?
  • Are you taking or have you recently taken any prescription or over the counter medicine(s)?
  • Do you wear contact lenses?
  • Joint Replacement. Have you had an orthopedic total joint (hip, knee, elbow, finger) replacement?
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  • Are you taking or scheduled to begin taking an antiresorptive agent (like Fosamax®, Actonel®, Atelvia, Boniva®, Reclast, Prolia) forosteoporosis or Paget’s disease?.
  • Since 2001, were you treated or are you presently scheduled to begin treatment with an antiresorptive agent (like Aredia®, Zometa®, XGEVA) for bone pain, hypercalcemia or skeletal complications resulting from Paget’s disease, multiple myeloma or metastatic cancer?
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  • Do you use controlled substances (drugs)?
  • Do you use tobacco (smoking, snuff, chew, bidis)?
  • If so, how interested are you in stopping?
  • Do you drink alcoholic beverages?

  • Questions for Women Only:

  • Are You Pregnant?
  • Taking birth control pills or hormonal replacement?
  • Nursing?
  • Rows

  • Please mark (X) your response to indicate if you have or have not had any of the following diseases or problems.

  • Artificial (prosthetic) heart valve:
  • Previous infective endocarditis:
  • Damaged valves in transplanted heart:

  • Congenital heart disease (CHD)

  • Unrepaired, cyanotic CHD:
  • Repaired (completely) in last 6 months:
  • Repaired CHD with residual defects:

  • Except for the conditions listed above, antibiotic prophylaxis is no longer recommended for any other form of CHD.

  • Cardiovascular disease:
  • Angina:
  • Arteriosclerosis:
  • Congestive heart failure:
  • Damaged heart valves:
  • Heart attack:
  • Heart murmur:
  • Low blood pressure:
  • High blood pressure:
  • Other congenital heart defects:
  • Mitral valve prolapse:
  • Pacemaker:
  • Rheumatic fever:
  • Rheumatic heart disease:
  • Abnormal bleeding:
  • Anemia:
  • Blood transfusion:
  • AIDS or HIV infection:
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  • Arthritis:
  • Autoimmune disease:
  • Rheumatoid arthritis:
  • Systemic lupus erythematosus:
  • Asthma:
  • Asthma:
  • Bronchitis:
  • Emphysema:
  • Sinus trouble:
  • Tuberculosis:
  • Cancer/Chemotherapy/Radiation Treatment:
  • Chest pain upon exertion:
  • Chronic pain:
  • Diabetes Type I or II:
  • Eating disorder:
  • Malnutrition:
  • Gastrointestinal disease:
  • G.E. Reflux/persistent heartburn:
  • Ulcers:
  • Thyroid problems:
  • Stroke:
  • Glaucoma:
  • Hepatitis, jaundice or liver disease:
  • Epilepsy:
  • Fainting spells or seizures:
  • Neurological disorders:
  • Sleep disorder:
  • Do you snore?
  • Mental health disorders?
  • Recurrent Infections:
  • Kidney problems:
  • Night sweats:
  • Osteoporosis:
  • Persistent swollen glands in neck:
  • Severe headaches/migraines:
  • Severe or rapid weight loss:
  • Sexually transmitted disease:
  • Excessive urination:
  • Has a physician or previous dentist recommended that you take antibiotics prior to your dental treatment?
  • Format: (000) 000-0000.
  • Do you have any disease, condition, or problem not listed above that you think I should know about?

  • NOTE: Both doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment.

    I certify that I have read and understand the above and that the information given on this form is accurate. I understand the importance of a truthful health history and that my dentist and his/her staff will rely on this information for treating me. I acknowledge that my questions, if any, about inquiries set forth above have been answered to my satisfaction. I will not hold my dentist, or any other member of his/her staff, responsible for any action they take or do not take because of errors or omissions that I may have made in the completion of this form.

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