Patient's Health Form Update

The Family Dental Center
Patient Name
Today's Date

MonthDayYear
Date
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth

MonthDayYear
Date
Occupation
Social Security Number
Email
example@example.com
Cell Number
Please enter a valid phone number.
Dental History
Reason For Today's Visit
Date of Last Dental Exam and Cleaning

MonthDayYear
Date
Please Select Any Conditions That Apply:

Bad BreathBleeding GumsFood Collection Between TeethSores or Growths in Your MouthLoose Teeth or Broken FillingsPeriodontal TreatmentSensitively to ColdSensitively to HotSensitively to SweetsSensitivity When BitingGrinding TeethClicking or Popping Jaw
How Often Do You Floss?
How Often Do You Brush?
Patient Medical History
Physician
Office Phone
Please enter a valid phone number.
Date of Last Exam

MonthDayYear
Date
Are You Under Medical Treatment Now?

YesNo
If Yes, What For?
Have You Ever Been Hospitalized For Any Surgical Operation Or Serious Illness?

YesNo
If Yes, What For?
Please List Medications You Are Currently Taking Including Vitamins and Herbal Supplements.
Please Select All Drug Allergies

AspirinSulfaBarbituratesLatexCodeineLocal AnestheticPenicillinOther
IN ORDER TO SERVE YOU BETTER DURING ORAL CANCER SCREENINGS, PLEASE ANSWER THE FOLLOWING:
Do You Use Nicotine Products In The Form Of Vaping Or E-Cigarettes?

YesNo
Do You Use Tobacco?

YesNo
Do You Drink Alcohol?

YesNo
Do You Use Cocaine or Other Drugs?

YesNo
Have You Ever Taken Any Of The Group Of Drugs Collectively Referred To As Bisphosphonates? (This Would Include Drugs For Osteoporosis Such As Samax, Boniva, Actonel, Atelvia, And Reclast)

YesNo
Do You Take Any Blood Thinners> Including Daily Aspirin?

YesNo
Please Select If You Have Or Have Had Any Of The Following:

High Blood PressureStrokeRadiation TherapyAids or HIV InfectionHeart AttackLow Blood PressureBlood DiseaseThyroid ProblemArtificial Heart ValvesEmphysema/COPDChemotherapyArthritisDiabetes Type 1 Or Type 2Hay Fever/AllergiesLeukemiaJoint Replacement/ImplantHeart DiseaseTuberculosisSteroid TreatmentStomach Trouble/UlcersCardiac PacemakerPersistent CoughKidney DiseaseGlaucomaHeart MurmurAsthmaLiver DiseaseCataractsAnginaAnemiaHepatitis/JaundiceEpilepsy/SeizuresChest PainsCancerSexually Transmitted DiseaseAutism/Spectrum DisordersOther
Women Only:
Are You Pregnant, Or Do You Think You May Be Pregnant?

YesNo
Are You Nursing?

YesNo
Are You Taking Birth Control?

YesNo
Signature

Clear
Patient, Parent, or Guardian
Date

MonthDayYear
Date
Should be Empty:

The Family Dental Center

Dental History

Patient Medical History