Health History Form

Personal Information

 

Name:______________________________________ Date of Birth______________________

Primary Phone:_________________________ Secondary Phone________________________

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Email Address:________________________________________________________________

Home Address (City, State, Zip):__________________________________________________

Emergency Contact (Name and Number):___________________________________________

 

 

Insurance Information

 

Employed By:___________________________ Dental Insurance Company:_______________

Insurance Member ID Number:_________________ Your SSN:________________________

Are you the policyholder? Yes No If not, who?______________________________________

Policy Holder DOB:__________________________ Policy Holder SSN:____________________

 

Dental History

 

When was your last dental visit?____________________________________

Is Your Dental Health Important? ❑ Not Important ❑ Somewhat Important ❑ Very Important

What is Your Main Reason for Your Visit here today?__________________________________________

 

Do You Have Tooth Pain/Sensitivity? ❑ Yes ❑ No

Do You Have Any Broken/Chipped Teeth? ❑ Yes ❑ No

Do You Experience Jaw Pain? ❑ Yes ❑ No

Do Your Gums Ever Bleed? ❑ Yes ❑ No

Have You Used Tooth Whitening Products? ❑ Yes ❑ No

Have You Ever Had Braces? ❑ Yes ❑ No

Have You Ever Had a ‘Root Canal?’ ❑ Yes ❑ No

Are You Missing Any Teeth? ❑ Yes ❑ No

Do You Wear a Dental Night Guard? ❑ Yes ❑ No

Do You Experience Dry Mouth? ❑ Yes ❑ No

Do You Use Fluoride Mouth Rinse? ❑ Yes ❑ No

Have You Ever Had Gum (Periodontal) Treatments? ❑ Yes ❑ No

Does Anyone in Your Family Wear Dentures? ❑ Yes ❑ No

Do You Require Antibiotics Before Dental Treatment? ❑ Yes ❑ No

Ever had a Serious Problem with Previous Dental Work? ❑ Yes ❑ No

You Drink Soda Pop and/or Energy Drinks ❑Never ❑Sometimes ❑Frequently

You Drink Coffee and/or Tea ❑Never ❑Sometimes ❑Often

Your Favorite Snack is?________________________

 

How Often Do You Brush your Teeth?_______________________Floss?___________________

 

How Did You Hear About Our Dental Practice?________________________________________

 

What is the MOST important thing you are looking for in your dentist and dental office?_______________________________________________________________________

Health History

 

Are You Currently Under Care of a Physician? ❑ Yes ❑ No

Where Do You Go For Medical Care?________________________Most Recent Visit?____________

Height?______________________ Weight?_____________

Do you use Tobacco in any form? ❑ Yes ❑ No How many years have you used?________

 

Allergies

 

Do You Have any Allergies or ”Bad Reactions” to the Following?

Penicillin ❑ Yes ❑ No

Clindamycin ❑ Yes ❑ No

Erythromycin ❑ Yes ❑ No

Latex ❑ Yes ❑ No

Metals ❑ Yes ❑ No

Other ❑ Yes ❑ No

 

If yes, describe details of your reaction:____________________________________________

 

Conditions

 

Do You Currently Have Any of the Following?

Alzheimer's ❑ Yes ❑ No

Anemia ❑ Yes ❑ No

Angina Pectoris ❑ Yes ❑ No

Arthritis ❑ Yes ❑ No

Anxiety ❑ Yes ❑ No

Artificial Heart Valve ❑ Yes ❑ No

Asthma ❑ Yes ❑ No

Acid Reflux ❑ Yes ❑ No

Cancer ❑ Yes ❑ No

Chest Pain ❑ Yes ❑ No

Heart Defects ❑ Yes ❑ No

Diabetes ❑ Yes ❑ No

Dialysis ❑ Yes ❑ No

Difficulty Breathing ❑ Yes ❑ No

Difficult Seeing ❑ Yes ❑ No

Difficulty Hearing ❑ Yes ❑ No

Depression ❑ Yes ❑ No

Drug Abuse History ❑ Yes ❑ No

Emphysema ❑ Yes ❑ No

Epilepsy ❑ Yes ❑ No

Endocarditis History ❑ Yes ❑ No

Glaucoma ❑ Yes ❑ No

HIV/AIDS ❑ Yes ❑ No

Heart Attack History ❑ Yes ❑ No

Heart Surgery History ❑ Yes ❑ No

Hemophilia ❑ Yes ❑ No

Hepatitis A, B, or C ❑ Yes ❑ No

High Blood Pressure ❑ Yes ❑ No

Joint Replacement History ❑ Yes ❑ No

Kidney Problems ❑ Yes ❑ No

Liver Problems ❑ Yes ❑ No

Osteoporosis ❑ Yes ❑ No

Pacemaker ❑ Yes ❑ No

Psychiatric Conditions ❑ Yes ❑ No

Pregnant/Nursing ❑ Yes ❑ No

Active STD or STI ❑ Yes ❑ No

Sinus Problems ❑ Yes ❑ No

Stroke History ❑ Yes ❑ No

Thyroid Problems ❑ Yes ❑ No

Tuberculosis ❑ Yes ❑ No

Ulcers ❑ Yes ❑ No

Explain Details:______________________________________________________________

 

Medications

Please List the Medications you Regularly Take: ________________________________________________________________________________________________________________________________________________________________________

 

Have You Ever Taken any Bisphosphonate drugs, such as Fosamax or Zoledronate? ❑ Yes ❑ No

Anything Else You Would Like us to Know Regarding Your Health Status? ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Thank You!