Health History Form
Name
*
First Name
Middle Name
Last Name
Date of Birth
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
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25
26
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28
29
30
31
Day
Please select a year
2026
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
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1976
1975
1974
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1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
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1958
1957
1956
1955
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1953
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1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Gender
*
Please Select
Male
Female
Heart valve problem requiring premedication or history of infective endocarditis
*
Yes
No
Have you had any surgeries or been hospitalized in the last 6 months
*
Yes
No
If yes, please explain
*
Do you smoke or have in the past
*
Yes
No
Do you chew tobacco or have in the past
*
Yes
No
History of chemical dependency/alcoholism
*
Yes
No
Sexually transmitted disease
*
Yes
No
Herpes Simplex Virus
*
Yes
No
Taking Warfarin or anticoagulants
*
Yes
No
Have you ever taken Fosamax, Reclast, Prolia or medications with Bisphosphonates
*
Yes
No
Joint replacement (total hip, pins, implant)
*
Yes
No
Diabetes
*
Yes
No
*
Type 1
Type 2
Prediabetic
Women Only
Pregnant/nursing How many weeks
Taking birth control/hormones
Yes
No
Allergies or prior reactions to — Select all that apply
Aspirin
Penicillin
Other antibiotics
Codeine
Sulfa
Sedatives
Latex
Local anesthetics
Ibuprofen
Other
If "Other" Please Explain
No known drug allergies
Sleep, Snoring & Apnea History
Do you snore or have you been told you do
*
Yes
No
Have you been told you stop breathing while asleep
*
Yes
No
Have you been diagnosed or treated for a sleep disorder
*
Yes
No
TMJ History
Do you clench or grind your jaws frequently
*
Yes
No
Does it hurt when you chew or open wide to take a bite
*
Yes
No
Do you have earaches or pain in front of the ears
*
Yes
No
Do you have jaw symptoms or headaches upon awakening in the morning
*
Yes
No
Are you aware of an uncomfortable bite
*
Yes
No
Have you had a blow to the jaw (trauma)
*
Yes
No
Are you a habitual gum chewer
*
Yes
No
Are you aware of your jaw popping, clicking or making noises
*
Yes
No
Do you wear a nightguard or retainer
*
Yes
No
Please indicate yes or no if you have had or currently have any of the following conditions:
AIDS / HIV
*
Yes
No
Abnormal Bleeding
*
Yes
No
Angina
*
Yes
No
Anxiety
*
Yes
No
Arthritis
*
Yes
No
Asthma
*
Yes
No
Autoimmune Disease
*
Yes
No
Blood Pressure issues
*
Yes
No
Cancer/Tumors
*
Yes
No
Depression
*
Yes
No
Dizziness/Fainting
*
Yes
No
Epilepsy/Seizures
*
Yes
No
Heart Disease
*
Yes
No
Hepatitis
*
Yes
No
Type?
*
A
B
C
Kidney Disease
*
Yes
No
Liver Disease
*
Yes
No
Mental Disorders
*
Yes
No
Pacemaker
*
Yes
No
Respiratory Problems
*
Yes
No
Sinus Problems
*
Yes
No
Stroke/TIA
*
Yes
No
If "Yes" When
*
Tuberculosis
*
Yes
No
Dental Health History
Answer each question with Yes or No.
General
Are you apprehensive about dental treatment
*
Yes
No
Have you had:
Problems with previous dental tx
*
Yes
No
Orthodontics/Braces
*
Yes
No
Wisdom teeth removed
*
Yes
No
Periodontal Tx or gum surgery
*
Yes
No
Do you gag easily
*
Yes
No
Does food catch between your teeth
*
Yes
No
Do you have difficulty chewing your food
*
Yes
No
Do your gums bleed easily
*
Yes
No
Do your gums feel swollen or tender
*
Yes
No
Have you had slow healing sores in/around your mouth
*
Yes
No
Do you have tooth pain with hot/cold/sweet/sour
*
Yes
No
Do you take fluoride supplements
*
Yes
No
Are you satisfied with the appearance of your teeth
Yes
No
How often do you brush?
x per week
How often do you floss?
x per week
Please list all medications and drugs you are taking or provide a medication list:
*
I have read and answered the above questions to the best of my knowledge and understand the importance of a truthful health history to assist the doctor in providing the best care possible.
Patient / Guardian Signature
*
Patient Name
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Should be Empty: