Health History
Please make sure you answer each field that applies to you.
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Sex
Please Select
Male
Female
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Emergency Contact
Emergency Contact Phone Number
Who may we thank for referring you to our office?
What is the name of your general Dentist?
Estimated Date of last visit with your Dentist?
-
Month
-
Day
Year
Date
Are you currently in orthodontic treatment?
What is the name of your Orthodontist?
Name of Primary Dental Insurance
Dental Insurance Phone Number
Employer Name
Subscriber Full Name
Subscriber Date of Birth
-
Month
-
Day
Year
Date
Subscriber Address
City, State, Zip Code
Relationship to Patient
Subscriber (Member) ID
Some plans use the member's social security number as the Member ID
Group Number
Subscriber Social Security Number
This information is only needed for patients with insurance and is ONLY used for verifying insurance benefit purposes and will not be shared.
Name of Secondary Dental Insurance (If Any)
Secondary Dental Insurance Phone Number
Secondary Employer Name
Secondary Subscriber Full Name
Secondary Subscriber Date of Birth
-
Month
-
Day
Year
Date
Secondary Subscriber Address
City, State, Zip Code
Relationship to Patient
Subscriber (Member) ID
Group Number
Name of Medical Insurance
Medical Insurance Phone Number
Employer Name
Subscriber Full Name
Subscriber Address
City, State, Zip Code
Relationship to Patient
Subscriber (Member) ID
Group Number
Allergic to Penicillin:
Yes
No
Allergic to Sulfa Drugs:
Yes
No
Allergic to Codeine:
Yes
No
Able to Take Ibuprofen:
Yes
No
Allergic to Latex:
Yes
No
Allergic to Other Medications or Narcotics:
Yes
No
If you answered yes to other medications, list the names of Those medications Here:
AIDS/HIV Infection:
Yes
No
Asthma:
Yes
No
Autoimmune Disease:
Yes
No
Arthritis:
Yes
No
If Yes, What Kind:
Blood Clotting Problems:
Yes
No
High Blood Pressure:
Yes
No
Heart Murmur:
Yes
No
Congenital Heart Defect:
Yes
No
Cardiovascular Disease:
Yes
No
Cardiac Pacemaker:
Yes
No
History of Stroke:
Yes
No
History of Heart Attack:
Yes
No
History of Blood Transfusion:
Yes
No
Shortness of Breath:
Yes
No
History of Cancer:
Yes
No
If Yes, What Kind:
History of Radiation Treatment:
Yes
No
Rheumatic Fever:
Yes
No
Rheumatic Heart Disease:
Yes
No
Epilepsy:
Yes
No
History of Seizures:
Yes
No
Liver Problems:
Yes
No
Hepatitis:
Yes
No
Jaundice:
Yes
No
Kidney Problems:
Yes
No
Gallbladder Trouble:
Yes
No
Stomach Ulcers:
Yes
No
Thyroid Problems:
Yes
No
Tuberculosis:
Yes
No
Joint Replacement:
Yes
No
Fever Blisters:
Yes
No
Gag Reflex:
Yes
No
Dry Mouth:
Yes
No
Bronchitis:
Yes
No
Sinus Trouble:
Yes
No
Difficulty Breathing Through Your Nose:
Yes
No
Low Blood Pressure:
Yes
No
Eating Disorder:
Yes
No
Anemia:
Yes
No
Empheysema/COPD:
Yes
No
Mitral Valve Prolapse:
Yes
No
Lupus:
Yes
No
Diabetes:
Yes
No
Mental Health Problems:
Yes
No
What is your current Weight:
What is your Height:
Do You Have Popping, Clicking, or Soreness of your Jaw Just In Front of the Ears:
Yes
No
Do You Clench or Grind Your Teeth:
Yes
No
Do You Have Limited Opening of Your Mouth:
Yes
No
Are You Currently Under the Care of a Physician:
Yes
No
If Yes, Name of Physician:
Phone Number of Physician:
What is the Condition Being Treated:
List any serious illnesses or hospitalizations you've had in the past:
Do you Smoke:
Yes
No
If Yes, mark all that apply:
Tobacco
Marijuana
Vape
Do yu Drink alcohol:
Yes
No
If Yes, mark all that apply
Beer
Wine
Liquor
Is your alcohol use:
Daily
Weekly
Occasionally (once a month or less)
Do you take diet pills:
Yes
No
Name of diet pills:
Any drug use: Check all that apply:
Cocaine
Marijuana
Crack
Heroin
Benzodiazepines, etc.
Any adverse reaction to anesthesia:
Yes
No
What was the reaction:
Are you taking blood thinners:
Yes
No
Do you take insulin:
Yes
No
Have you been diagnosed with Autism:
Yes
No
List all medications (over the counter also) currently taking:
For Women Only:
Are you pregnant:
Yes
No
Date of last menstrual cycle:
How many pregnancies have you had:
Number of live births:
Are you currently nursing:
Yes
No
Are you on hormone replacement therapy:
Yes
No
Are you on birth control pills/fertility drugs:
Yes
No
Any disease, illness, or condition not listed:
By signing below, I certify that all of the above information is true to the best of my knowledge:
Date
-
Month
-
Day
Year
Date
Dentist Signature (Dentist will sign after patient submission)
Dentist Signature Date
-
Month
-
Day
Year
Date
Continue
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