Patient Health History
Please complete to the best of your ability.
Patient Name
*
Date of Birth
*
/
Month
/
Day
Year
Date
DENTAL HISTORY
Please state the reason for today's visit
*
Date of last visit to a dentist
*
/
Month
/
Day
Year
Date
Date of last dental cleaning
*
/
Month
/
Day
Year
Date
Do you know the date of your last full mouth x-rays?
*
No
Yes
If yes, what was the date of your last full mouth x-rays? (If no, leave blank)
/
Month
/
Day
Year
Date
Previous Dental Office/Dentist
Address
Phone
Format: (000) 000-0000.
How often do you have dental visits/examinations/cleanings?
How often do you brush?
*
3+ times per day
2 times per day
1 time per day
Weekly
Seldom
How often do you floss?
*
1+ times per day
2-6 times per week
1-6 times per month
Seldom
Never
Do you use other dental aids?
Toothpicks
Sonicare
Waterpik
Floss aids
Electric brush
Are you happy with the appearance of your teeth and smile?
*
Yes
No
If no, please describe:
Do you have any dental problems at this time?
*
Yes
No
If yes, please describe:
Have you had any of the following? (Please check the box to indicate "YES". Leave blank if "NO")
Please describe any "YES" answers from above.
Do you do any of the following? (Please check the box to indicate "YES". Leave blank if "NO")
Please describe any "YES" answers from above.
MEDICAL HISTORY
Physician's name/clinic
*
City
*
Phone
*
Format: (000) 000-0000.
Date of last physical/medical exam: (month/year)
*
/
Month
/
Day
Year
Date
Have you been a patient in a hospital in the past 5 years?
*
Yes
No
If yes, for what?
Have you had any allergic reactions (rash, hives, anaphylaxis) or adverse reactions (nausea, upset stomach, dizziness) to any medications or substances?
*
Yes
No
If yes, please describe substance and reaction:
Have you ever been told to take antibiotic pre-medication before dental treatment?
*
Yes
No
If yes, for what?
Do you currently or have you in the past used tobacco/nicotine?
*
Yes
No
If yes, type, amount, and years:
Women: Are you pregnant?
Yes
No
If yes, how many weeks along are you?
Women: Are you breastfeeding?
Yes
No
Please indicate any condition you have had in the past or currently have: (Please check the box to indicate "YES". Leave blank if "NO")
Do you have any disease, problem, or condition not listed? If yes, please describe. (If no, leave blank.)
Please list current prescription medications, over-the-counter medications, vitamins, herbals, and/or supplements: (Please be sure to click "Save Row" for each medication entered)
Pharmacy of choice:
*
Pharmacy phone number:
*
Please enter a valid phone number.
Format: (000) 000-0000.
I have answered this health history to the best of my knowledge.
Signature (Parent signature if minor)
*
Today's Date
*
/
Month
/
Day
Year
Date
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