Language
English (US)
Spanish (Latin America)
Health History Form
Please note that it is important to fill in all the fields before submitting. Thank you.
Patient Name
*
First Name
Middle Name
Last Name
SSN
Home Phone Number
*
Please enter a valid phone number.
E-mail
*
example@example.com
Physician's Name
Phone Number
Please enter a valid phone number.
Hospital/HMO
Please enter a valid phone number.
In case of Emergency: Contact Details
His / Her name
*
Phone Number
*
Please enter a valid phone number.
Dental History
Why have you come to the dentist today?
Are you currently in pain?
*
Yes
No
Do you require antibiotics before dental treatment?
*
Yes
No
Your current dental health is
*
Good
Fair
Poor
Have you ever had a serious/difficult problem associated with any previous dental work?
*
Yes
No
Do you floss daily?
*
Yes
No
Brush daily?
*
Yes
No
Type of bristles on your toothbrush?
*
Yes
No
Have you ever had gum treatment?
*
Yes
No
Do your gums ever bleed?
*
Yes
No
Ever Itch?
*
Yes
No
Have you ever had periodontal disease?
*
Yes
No
Do you now or have you ever experienced pain/discomfort in your jaw joint (TMJ/TMD)?
*
Yes
No
Are your teeth sensitive to
*
Heat
Cold
Anything else?
*
Do you have any loose teeth?
*
Yes
No
Do you still have wisdom teeth?
*
Yes
No
Would you like fresher breath?
*
Yes
No
Whiter teeth?
*
Yes
No
Are you happy with the way your smile looks?
*
Yes
No
If not, what would you change?
*
Medical History
PLEASE ANSWER ALL QUESTIONS
Has there been any change in your health in the past two years?
*
Yes
No
Date of last medical examination?
-
Month
-
Day
Year
Date
Are you under any physician's care now?
*
Yes
No
Have you ever been hospitalized or had any serious illness?
*
Yes
No
Are you taking any medications or drugs including over the counter medications or oral contraceptives?
*
Yes
No
Do you take anticoagulants or blood thinners?
*
Yes
No
Are you using any recreational drugs or tobacco?
*
Yes
No
Are you pregnant? Months
*
Yes
No
Are you nursing at present?
*
Yes
No
DO YOU HAVE NOW OR HAVE YOU HAD ANY OF THE FOLLOWING:
Heart disease, pacemaker, irregular heartbeat or endocarditis
*
Yes
No
Shortness of breath with limited activity or when lying down
*
Yes
No
Chest pain or angina or heart attack
*
Yes
No
Rheumatic fever or rheumatic heart disease
*
Yes
No
Heart murmur, mitral valve prolapse, or heart defect from birth
*
Yes
No
Stroke, numbness, or tingling sensations
*
Yes
No
High or low blood pressure
*
Yes
No
Fainting spells, convulsions or epilepsy
*
Yes
No
Nervous break down, emotional problems, anxiety or depressive disorder
*
Yes
No
Lung disease:T.B., asthma, emphysema
*
Yes
No
Liver disease: Hepatitis, cirrhosis...
*
Yes
No
Prolonged bleeding following injuries or surgery, transfusions
*
Yes
No
Thyroid , Diabetes
*
Yes
No
Any limitation of activities or Diet
*
Yes
No
Venereal disease (syphilis, gonorrhea, herpes, warts, other)
*
Yes
No
Blood disorder (anemia, leukemia or other)
*
Yes
No
Cancer or cancer treatment (Radiation, Chemotherapy, Surgery)
*
Yes
No
Thrombophlebitis
*
Yes
No
Kidney disease, dialysis or transplant
*
Yes
No
AIDS or Immunosuppressive disorder
*
Yes
No
Ulcers, stomach or intestinal disease
*
Yes
No
An unusual reaction to any dental treatment?
*
Yes
No
If "yes" Please Explain
*
Arthritis, Rheumatism, painful joints, osteoporosis
*
Yes
No
Artificial implants, hip or other
*
Yes
No
Any visual disorder (glaucoma or other)
*
Yes
No
Any hearing impairment
*
Yes
No
DO YOU HAVE ANY ALLERGY TO
Novacaine, xylocaine, any anesthetics
*
Yes
No
Penicillin or other antibiotics
*
Yes
No
Aspirin, codeine, valium, barbiturates or other pain medications
*
Yes
No
Latex, other allergies, hayfever, hives
*
Yes
No
Anything that has not been asked??
*
Yes
No
Vital Signs
Signature
*
Name
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
Date
Submit
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