woodlandsvillagebraces.com - Health History Form

Health History Form
Please fill in this form completely down to the signature. The bottom boxed area is for office use. Thank you.
Patient Name:

First NameMiddle NameLast Name
MaleFemale
Date of Birth

MonthDayYear
Date
Age
Parent Name:

First NameLast Name
Driver’s License Number
Expiration

MonthDayYear
Date
How did you hear about our office?
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Other Phone
Please enter a valid phone number.Format: (000) 000-0000.
Privacy permission given to
Emergency Contact
Relationship
Telephone
Please enter a valid phone number.Format: (000) 000-0000.
If Applicable: Who’s accompanying the child today?
YesNo
Person responsible for account
Occupation
Relationship
Email
example@example.com
Who is your general dentist?
Telephone
Please enter a valid phone number.Format: (000) 000-0000.
Last Visit
Who else has examined you?
PATIENT MEDICAL AND DENTAL HISTORY

SELECT ALL THAT APPLY
YesNo
YesNoOther
Jaw painJaw lock (couldn’t open or close)Jaw popping or clickingInjury to the face or headEar painSevere headachesBlood disorderDiabetesHepatitis A or B or CHIV or AIDS or ARCAn STDHigh or low blood pressureKidney problemsLiver diseaseOrgan transplantsArtificial joints or bonesHemophiliaHeart murmurHeart surgeryHeart attack or strokePacemakerEpilepsyTuberculosisCongenital defectRadiation therapyParalysisTransfusionCancerChemotherapyPsychiatric problems or depressionBrain disorderOther
Other surgeries or hospitalizations?
YesNo
GoodPoor
YesNo
Which ones?
YesNo
YesNo
YesNo
YesNo
AnemiaArthritisAsthmaDifficulty breathingEmphysemaFaintingFever blistersRecurrent infectionsRheumatismShinglesSinus problemsUlcersVenereal diseaseWeight changeMouth infectionGum disease
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
By signing here, I confirm that the information that I have given today is correct to the best of my knowledge.
Signature (patient / guardian)

Clear
Date

MonthDayYear
Date
Please print your name
SAMPLE PHOTOS TO BE SENT BY TEXT
History / DX
Not to be treated
Concerns Prior to Tx
YesNo
YesNo
Appt Made
Follow up with,
CallTextEmail
Should be Empty:

Health History Form

PATIENT MEDICAL AND DENTAL HISTORY

SAMPLE PHOTOS TO BE SENT BY TEXT