Health History
Name
First Name
Last Name
Birthdate
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Age
Height
Weight
1. Are you in good health?
Yes
No
2. Have there been any changes in your general health in the past year?
Yes
No
3. Are you under the care of a physician?
Yes
No
Date of last visit
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
If so, for what are you being treated?
4. Have you had any illness, operation or been hospitalized in the past five years?
Yes
No
If so, describe
5. Do you have unhealed/recurrent injuries or inflamed areas, growths or sore spots in or around your mouth?
Yes
No
If so, describe where
6. Do you have a prosthetic joint/implant?
Yes
No
If so, describe where
7. Have you had a heart valve replacement or vascular graft?
Yes
No
8. Have you ever had general anesthesia?
Yes
No
9. Have you, or a family member, had any unusual or serious reactions to general anesthesia?
Yes
No
DENTAL HISTORY
General Dentist
Office Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Specialty Dentist
Office Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Why are you seeking dental treatment?
Have you ever had any serious trouble associated with previous dental treatment?
Does Dental Treatment make you nervous?
No
Slightly
Moderately
Extremely
Date of your last dental visit?
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Have you ever been treated for periodontal disease (gum disease, pyorrhea, trench mouth)?
Do you have or have you ever had any of the following?
Rows
No
Yes
If yes, please explain
Bleeding, sore gums
Unpleasant taste/ bad breath
Frequent blisters, lips/mouth
Burning tongue/ lips
Swelling/ lumps in mouth
Orthodontics (braces)
Biting cheeks/ lips
Clicking/ popping jaw
Difficulty opening or closing jaw
Loose Teeth
Sensitive to hot
Sensitive to cold
Sensitive to sweets
Sensitive to biting
Food impaction
Clenching/ grinding
Shifting of teeth
Change in bite
Chest pain/ angina
Cardia pacemaker
Pneumonia, bronchitis, chronic cough
Snoring
Sleep apnea/ CPAP
Difficult breathing/ other lungs trouble
Bleeding tendency/ abnormal bleed
Thyroid trouble
Low blood sugar
Kidney trouble
Are you on dialysis?
Osteoporosis
Stomach/ acid reflux
Contagious diseases
Problem with immune system
A tumor or growth
A history of alcohol abuse
A history of marijuana or other drug use
Mental health problems/ anxiety/ depression
Pain or clicking of jaws when eating
Bleeding, sore gums
Yes
No
Unpleasant taste/ bad breath
Yes
No
Frequent blisters, lips/mouth
Yes
No
Burning tongue/ lips
Yes
No
Swelling/ lumps in mouth
Yes
No
Orthodontics (braces)
Yes
No
Biting cheeks/ lips
Yes
No
Clicking/ popping jaw
Yes
No
Difficulty opening or closing jaw
Yes
No
Loose Teeth
Yes
No
Sensitive to hot
Yes
No
Sensitive to cold
Yes
No
Sensitive to sweets
Yes
No
Sensitive to biting
Yes
No
Food impaction
Yes
No
Clenching/ grinding
Yes
No
Shifting of teeth
Yes
No
Change in bite
Yes
No
MEDICAL HISTORY
Primary Care Physician
Physician Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Specialty Doctor
Office Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Are you currently under the care of a physician?
Yes
No
If so, what is the condition being treated?
Have you ever been hospitalized or had a serious illness?
Yes
No
If yes, please explain
Have you ever had excessive bleeding following an extraction, or do cuts take longer to heal now than previously?
Yes
No
Women Only
Are you pregnant?
Yes
No
Due Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Are you nursing?
Yes
No
Are you taking birth control pills?
Yes
No
Are you ALLERGIC to or have you had any reaction to the following?
Rows
Yes
No
Local anesthetics (Novocain, Lidocaine)
Barbiturates/ sedatives/ sleeping pills
Antibiotics (Penicillin, Bactrim, Keflex)
Aspirin or codeine
Sulfa drugs
Sodium pentothal/Valium /other tranquilizers
Amoxicillin
Codeine or other narcotics
Latex
Soy
Eggs / yolk
Sulfites
Other allergies
Are you currently taking any of the following?
Rows
Yes
No
Antibiotics
Sulfa Drugs
Blood Pressure Medication
Thyroid Medication
Cortisone/ steroids
Antihistamines (allergy, cold med)
Tranquilizers
Herbal supplements or homeopathic remedy
Insulin/ Diabetes medication
Recreational drugs
Digitalis/ Heart medication
Nitroglycerin
Diet pills
Blood thinners (Coumadin, Plavix, Aspirin, Vitamin E, Ginko biloba, Aggrenox, Pradaxa, Fish oil)?
Yes
No
Are you taking, or have you ever taken bone density meds, RANKL inhibitors or bisphosphonates such as Denosumab, Fosamax, Boniva, Actonel, IV-Zometa, Aredia, Reclast, or Evista in the past 12 years?
Yes
No
Tranquilizers, sleeping pills, anti-depressants, and/or narcotics on a regular basis?
Yes
No
If so, please list:
Please list all medications you are currently taking & Reason for use:
**If you are taking more than 5 medications, please provide us with a full list on a separate sheet of paper Vitamins/Supplements?
Do you use tobacco in any form?
Yes
No
If so, how much?
Do you use alcoholic beverages (more than 2 drinks per day)?
Yes
No
How much?
Do you use any recreational drugs?
Yes
No
If so, which one(s)? How often?
Do you have or have you ever had any of the following?
GENERAL
Tire easily, weakness
Yes
No
Marked weight change
Yes
No
Night sweats
Yes
No
Persistent fever
Yes
No
SKIN
Eruptions (rash, hives)
Yes
No
Changes in skin color
Yes
No
EYES
Visual change
Yes
No
Glaucoma
Yes
No
Vision loss
Yes
No
NOSE
Frequent Nosebleeds
Yes
No
Sinus problems
Yes
No
THROAT
Soreness/ hoarseness
Yes
No
NERVOUS SYSTEM
Stroke
Yes
No
Headaches/ migraines
Yes
No
Convulsions/ epilepsy
Yes
No
Numbness/ tingling
Yes
No
Dizziness/ fainting
Yes
No
Psychiatric treatment
Yes
No
RESPIRATORY
Tuberculosis
Yes
No
Emphysema
Yes
No
Asthma/ hay fever
Yes
No
Persistent cough
Yes
No
Sputum production (phlegm)
Yes
No
Cough up bloody sputum
Yes
No
Difficulty breathing while lying down
Yes
No
ENDOCRINE
Diabetes
Yes
No
Family history of Diabetes
Yes
No
If yes, please elaborate
Thyroid condition/ goiter
Yes
No
Other
HEART/BLOOD VESSELS
Rheumatic fever
Yes
No
Heart murmur
Yes
No
Chest pain/ discomfort
Yes
No
Heart attack/ trouble
Yes
No
Shortness of breath
Yes
No
Swelling of ankles
Yes
No
High blood pressure
Yes
No
Congenital heart disease
Yes
No
Mitral valve prolapse
Yes
No
Artificial heart valve
Yes
No
Pacemaker
Yes
No
Heart surgery
Yes
No
Other
BONE/ MUSCLES
Arthritis/ rheumatism
Yes
No
Artificial joint/ limbs
Yes
No
DIGESTIVE SYSTEM
Hepatitis
Yes
No
Jaundice
Yes
No
Ulcers
Yes
No
Change in appetite
Yes
No
Black, bloody or pale stools
Yes
No
URINARY
Kidney disease
Yes
No
Frequent urination (night)
Yes
No
Burning on urination
Yes
No
Urethral discharge
Yes
No
Bloody urine
Yes
No
Venereal disease
Yes
No
BLOOD
Bruise easily
Yes
No
Anemia
Yes
No
Blood transfusion
Yes
No
OTHERS
Eating disorder
Yes
No
Radiation therapy
Yes
No
Chemotherapy
Yes
No
Tumors/growths
Yes
No
Cancer
Yes
No
HIV/AIDS
Yes
No
Signature
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Should be Empty: