thedentalmasters.org - Belmont Health History Form

Belmont Health History Form
Patient Name
Birth Date

MonthDayYear
Date
Date Created

MonthDayYear
Date
Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may hav, or medication that you may be taking.
Are you under the physician's care now?

YesNo
If yes
Have you ever been hospitalized or had a major operation?

YesNo
If yes
Have you ever had a serious head or neck injury?

YesNo
If yes
Are you taking any medications, pills, or drugs?

YesNo
If yes
Have you ever taken fosamax, Boniva, Actonel or any other medications containing bisphosphonates?

YesNo
If yes
Do you use tobacco?

YesNo
Do you use controlled substances?

YesNo
If yes
Women: Are you...

Pregnant/Trying to get pregnantNursingTaking oral contraceptives
Are you allergic to any of following?

AspirinMentalSeasonalLatexPenicillinCodeineSulfa DrugsOther

Do you have, or have you had, any of the following?

Have you ever had serious illness not listed above?

YesNo
If yes
Comments
To the best of my knowledge, the questions on this form have been accurately answered. I understand providing incorrect information can be dangerous to my (or patient's) health.It is my responsibility to inform the dental office of any changes in medical status.
Signature of patient, parent or guardian

Clear
Date

MonthDayYear
Date
Should be Empty: