Dental Patient Health History Form

Dental Patient Health History Form

Please provide your personal, dental, and medical history to help us deliver the best possible dental care.
Full Name*

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Date
Height (cm or in)*
Weight (kg or lbs)*
Sex*

MaleFemaleOther
Occupation*
Home Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email Address*
example@example.com
Dental History

Please provide details about your dental treatments, symptoms, and oral hygiene habits.
Which of the following dental treatments or restorations have you had?*

FillingsCrowns or BridgesRoot Canal TreatmentDental ImplantsBraces or Orthodontic TreatmentDentures or PartialsExtractionsPeriodontal (Gum) treatmentsNoneOther
Are you currently experiencing any of the following dental symptoms?*

ToothacheSensitive TeethBleeding GumsLoose TeethJaw Pain or ClickingMouth SoresBad BreathClenching &/or GrindingProblems with Previous Dental WorkNoneOther
How often do you brush your teeth?*

Twice a day or moreOnce a dayA few times a weekRarely
How often do you floss?*

DailyA few times a weekRarelyNever
Please list any other dental conditions or concerns you have. Please type "none" if you do not have any other concerns.*
Medical History

Your medical history is important for safe and effective dental care. Please answer the following.
Physician's Name*
Physician's Phone Number*
Do you have or have you ever had any of the following medical conditions?*

Active TuberculosisAnginaAnemiaArthritisAutoimmune DiseaseBeen Exposed to Anyone with TuberculosisBleeding DisordersBlood Transfusion (specify when and why below)Cancer (specify type below)Cancer- ChemotherapyCancer- RadiationCardiovascular DiseaseChest Pain Upon ExertionChronic PainCongenital heart DefectsCongestive Heart FailureCough that Produces BloodDamaged Heart ValvesDiabetesDiabetes Type IDiabetes Type IIEating DisorderEpilepsy or SeizuresEmphysemaExcessive UrinationFainting SpellsG.E. Reflux / Persistent HeartburnGlaucomaGastrointestinal DiseaseHigh Blood PressureHIV/AIDSJoint ReplacementKidney DiseaseLiver DiseaseLow Blood PressureMalnutritionMental Health Disorders (specify below)Mitral Valve ProlapseNight SweatsNeurological Disorders (specify type below)OsteoporosisPacemakerPersistent Cough for 3 Weeks or MorePersistent Swollen Neck GlandsRecurrent Infections (specify type below)Rheumatic Heart DiseaseRheumatic feverRheumatoid ArthritisSevere Headaches / MigrainesSevere or Rapid Weight LossSexually Transmitted DiseaseSinus TroubleSleep ApneaSleep DisorderStrokeSystemic Lupus ErythematosusThyroid ProblemsUlcersNoneOther
Please provide details for any 'Yes' answers above.
Please list any recent changes in your health or new diagnoses.
Have you been hospitalized or had any operations in the past 5 years?*

YesNo
If yes, please provide details about hospitalizations or operations.
Please list all medications you are currently taking (including over-the-counter and supplements). Please type "none" if you do not take any medications or supplements.*
Do you have any allergies*

YesNo
If 'Yes', please select any allergies you have:*

Local AnestheticsMetalsAspirinLatexPenicillinIodineOther AntibioticsShellfishSedativesPollenSulfa DrugsPet danderCodeine / NarcoticsOther MedicationsFoodNoneOther
Please add any necessary details regarding your allergies. Please type "none" if there are no additional details.*
Have you ever taken bisphosphonate medications (for bone health)?*

YesNoNot sure
If yes, please provide the medication name and duration of use.
Full Name (print)*
First name, middle initial, last name
Signature*
Should be Empty:

Dental Patient Health History Form

Dental History

Medical History