Health History Form
Patient Name:
*
Age:
*
DOB:
*
-
Month
-
Day
Year
Date
Name you like to be called:
*
Home Phone:
*
Please enter a valid phone number.
Format: (000) 000-0000.
School / Employer:
*
Grade:
SSN:
Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Who can we thank for referring you to our office?
*
Do you play an instrument?
*
Yes
No
Responsible Party
My relationship to the patient
*
Self
Parent
Other
Name:
*
Date of Birth:
*
-
Month
-
Day
Year
Date
Marital Status:
*
Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mailing Address (If different from above):
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
How long have you lived at this address?
*
Previous Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email Address:
*
example@example.com
Home Phone:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Cell Phone:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Employer:
*
Occupation:
*
Number of years employed:
*
Is there a second responsible party?
*
Yes
No
My relationship to the patient
*
Self
Patient
Other
Name:
*
Date of Birth:
*
-
Month
-
Day
Year
Date
Marital Status:
*
Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mailing Address (If different from above):
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
How long have you lived at this address?
*
Previous Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email Address:
*
example@example.com
Home Phone:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Cell Phone:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Employer:
*
Occupation:
*
Number of years employed:
*
Insurance Information
Do you have insurance coverage?
*
Yes
No
Insured's Name:
Insured's SSN:
Group Number:
Insurance Company:
Insurance Address:
Phone Number:
Please enter a valid phone number.
Format: (000) 000-0000.
Insured's Employer:
Do you have dual coverage?
Yes
No
Insured's Name:
Insured's SSN:
Group Number:
Insurance Company:
Insurance Address:
Phone Number:
Insured's Employer:
Medical/Dental History
Physician Name:
Physician Phone Number:
Please enter a valid phone number.
Format: (000) 000-0000.
Dentist Name:
Dentist Phone Number:
Please enter a valid phone number.
Format: (000) 000-0000.
Are you currently under any medical treatment?
*
Yes
No
Do you have pain, clicking, and/or popping noises in the jaw?
*
Yes
No
Are you aware of either clenching or grinding of teeth?
*
Yes
No
Do you have frequent headaches? If so, how often?
*
Do you have ear problems? (Aches, ringing, dizziness, fullness)
*
Yes
No
Do you have difficulty breathing through the nose?
*
Yes
No
Do you have habits such as nail biting, finger or thumb sucking, lip or cheek biting?
*
Yes
No
Do you have speech problems, or are you in speech therapy?
*
Yes
No
Have you had tonsils and/or adenoids removed?
*
Yes
No
Has there been any history of:
*
Joint Swelling
Asthma
TB
Aids
Kidney
Liver Condition
Epilepsy
Rheumatic Fever
None
Other major illnesses?
Do you bleed easily?
*
Yes
No
Is there a tendency to faint or become dizzy?
*
Yes
No
Do you have allergies? (Sulphur, penicillin, novocain, etc.) If so, to what?:
*
Are you taking any medication?
*
Do you have a heart condition?
*
Yes
No
Do you premedicate?
*
Yes
No
Cardiologist?
*
Do you have sleep apnea?
*
Yes
No
Do you smoke or chew tobacco?
*
Yes
No
Has there been any injuries to the teeth?
*
Yes
No
Have you had any permanent teeth extracted?
*
Yes
No
Have we treated any other family members? If so, who?
*
Signature
I understand where a appropriate credit report may be obtained.
Patient, Parent or Legal Guardian Signature:
*
Date
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: