Health History

Health History

Please make sure you answer each field that applies to you.
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Sex
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
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?

MonthDayYear
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

MonthDayYear
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

MonthDayYear
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:

YesNo
Allergic to Sulfa Drugs:

YesNo
Allergic to Codeine:

YesNo
Able to Take Ibuprofen:

YesNo
Allergic to Latex:

YesNo
Allergic to Other Medications or Narcotics:

YesNo
If you answered yes to other medications, list the names of Those medications Here:
AIDS/HIV Infection:

YesNo
Asthma:

YesNo
Autoimmune Disease:

YesNo
Arthritis:

YesNo
If Yes, What Kind:
Blood Clotting Problems:

YesNo
High Blood Pressure:

YesNo
Heart Murmur:

YesNo
Congenital Heart Defect:

YesNo
Cardiovascular Disease:

YesNo
Cardiac Pacemaker:

YesNo
History of Stroke:

YesNo
History of Heart Attack:

YesNo
History of Blood Transfusion:

YesNo
Shortness of Breath:

YesNo
History of Cancer:

YesNo
If Yes, What Kind:
History of Radiation Treatment:

YesNo
Rheumatic Fever:

YesNo
Rheumatic Heart Disease:

YesNo
Epilepsy:

YesNo
History of Seizures:

YesNo
Liver Problems:

YesNo
Hepatitis:

YesNo
Jaundice:

YesNo
Kidney Problems:

YesNo
Gallbladder Trouble:

YesNo
Stomach Ulcers:

YesNo
Thyroid Problems:

YesNo
Tuberculosis:

YesNo
Joint Replacement:

YesNo
Fever Blisters:

YesNo
Gag Reflex:

YesNo
Dry Mouth:

YesNo
Bronchitis:

YesNo
Sinus Trouble:

YesNo
Difficulty Breathing Through Your Nose:

YesNo
Low Blood Pressure:

YesNo
Eating Disorder:

YesNo
Anemia:

YesNo
Empheysema/COPD:

YesNo
Mitral Valve Prolapse:

YesNo
Lupus:

YesNo
Diabetes:

YesNo
Mental Health Problems:

YesNo
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:

YesNo
Do You Clench or Grind Your Teeth:

YesNo
Do You Have Limited Opening of Your Mouth:

YesNo
Are You Currently Under the Care of a Physician:

YesNo
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:

YesNo
If Yes, mark all that apply:

TobaccoMarijuanaVape
Do yu Drink alcohol:

YesNo
If Yes, mark all that apply

BeerWineLiquor
Is your alcohol use:

DailyWeeklyOccasionally (once a month or less)
Do you take diet pills:

YesNo
Name of diet pills:
Any drug use: Check all that apply:

CocaineMarijuanaCrackHeroinBenzodiazepines, etc.
Any adverse reaction to anesthesia:

YesNo
What was the reaction:
Are you taking blood thinners:

YesNo
Do you take insulin:

YesNo
Have you been diagnosed with Autism:

YesNo
List all medications (over the counter also) currently taking:
For Women Only:
Are you pregnant:

YesNo
Date of last menstrual cycle:
How many pregnancies have you had:
Number of live births:
Are you currently nursing:

YesNo
Are you on hormone replacement therapy:

YesNo
Are you on birth control pills/fertility drugs:

YesNo
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

MonthDayYear
Date
Dentist Signature (Dentist will sign after patient submission)
Dentist Signature Date

MonthDayYear
Date
Should be Empty:

Health History

For Women Only: