Health History
Date
/
Month
/
Day
Year
Date
Patient Name
DOB
Age
SSN
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Dental History
Dentists Name
Date of last dental exam/cleaning
/
Month
/
Day
Year
Date
Rows
Yes
No
Have you had Periodontal treatment?
Would you like your teeth whiter?
Do you grind your teeth, clench your jaw, or have TMJ issues such as clicking or locking?
Do your gums bleed easily?
Medical History
Doctors Name
Are you under the care of a physician currently?
Yes
No
If Yes, Please Specify
Are you currently taking any medication?
Yes
No
If Yes, please List medication
Are you pregnant?
Yes
No
If Yes, how many months?
Have you had any surgeries in the past?
Yes
No
If Yes, Please Specify
Please List any other Health Physical problems Symptoms we should be aware of
Please List any Allergies
Please circle YES or NO. Do you have, or have you ever had, any of the following:
Rows
Yes
No
AIDS/ HIV +
Asthma
Cancer
Angina
Bisphosphonate Therapy
Chemo/ Radiation
Artificial heart valve
Arthritis
Bleeding Problems
Cosmetic Surgery
Diabetes
Venereal Disease
Drug Addiction
Headaches/ Migraine
Kidney Disease
Eating Disorder
Heart Attack
Liver Disease/ Jaundice
Emphysema
Heart Murmur/Issue
Lung Disease
Epilepsy
Hepatitis
Pacemaker
Fainting/Dizzy Spells
High/Low Blood Pressure
Rheumatic Fever
Glaucoma
Joint Replacement
Sinus Trouble
Sleep Apnea
Tobacco Use
Stroke
Thyroid Problems
TMD or TMJ
Trauma to head/neck
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