Health History Form E-mail Today’s Date * As required by law, our office adheres to written policies and procedures to protect the privacy of information about you that we create, receive, or maintain. Your answers are for our records only and will be kept confidential subject to applicable laws. Please note that you will be asked some questions about your responses to this questionnaire and there may be additional questions concerning your health. This information is vital to allow us to provide appropriate care for you. This office does not use this information to discriminate. PATIENT INFORMATION First Name * Last Name * MI Home Phone Cell Phone Work Phone Preferred Method of Contact PhoneTextEmail Mailing Address City State Zip Height Weight Date of Birth Sex —Lütfen bir seçenek seçin—FemaleMaleOtherPrefer not to say Occupation Emergency Contact How did you hear about us? If you are completing this form for another person, what is your relationship to that person? Your Name Relationship Home Phone Cell Phone DENTAL INFORMATION Are your teeth sensitive to cold, hot, sweets or pressure? YesNo Do you have earaches or neck pains? YesNo Does food or floss catch between your teeth? YesNo Do you have any clicking, popping, or discomfort in the jaw? YesNo Is your mouth dry? YesNo Do you brux or grind your teeth? YesNo Have you had any periodontal (gum) treatments? YesNo Do you have sores or ulcers in your mouth? YesNo Have you ever had orthodontic (braces) treatment? YesNo Do you wear dentures or partials? YesNo Have you ever had any problems associated with previous dental treatment? YesNo Do you participate in active recreational activities? YesNo Is your home water supply fluoridated? YesNo Have you ever had a serious injury to your head or mouth? YesNo Do you drink bottled or filtered water? YesNo Are you currently experiencing dental pain or discomfort? YesNo If yes, how often? DailyWeeklyOccasionally Date of your last exam What was done at that time? Date of last dental x-rays Chief Complaint Reason for visit MEDICAL INFORMATION Are you currently under the care of a physician? YesNo Are you in good health? YesNo Has there been any change in your general health within the past year? YesNo Do you take blood thinners? YesNo Do you take aspirin on a regular basis? YesNo Are you taking or scheduled to begin taking either of the medications, alendronate (Fosamax) or risedronate (Actonel) for osteoporosis or Paget’s disease? YesNo Are you taking or have you recently taken any prescription or over the counter medicine(s)? YesNo Do you use controlled substances (drugs)? YesNo Do you use tobacco (smoking, snuff, chew, bidis)? YesNo Do you drink alcoholic beverages? YesNo Joint Replacement: Have you ever had an orthopedic total joint replacement? YesNo Are you in recovery? YesNo Have you had a serious illness, operation or been hospitalized in the past 5 years? YesNo Physician Name Phone Address/City/State/Zip If yes, what condition is being treated? Date of last physical exam If yes, list all medications, vitamins, herbal preparations and/or diet supplements: If so, how interested are you in stopping? (Tobacco) VerySomewhatNot Interested If yes, how much alcohol did you drink in the last 24 hours? If yes (Joint Replacement), date If yes, have you had any complications? YesNo If yes, how long have you been in recovery? If yes, what was the illness or problem? WOMEN ONLY Pregnant? YesNo Number of weeks Nursing? YesNo Taking birth control pills or hormonal replacements? YesNo MEDICAL INFORMATION (Continued) Allergies: Are you allergic or have you had a reaction to: Local anestheticsAspirinPenicillin or other antibioticsBarbiturates, sedatives, or sleeping pillsSulfa drugsCodeine or other narcoticsMetalsHay fever/seasonalLatex (rubber)IodineAnimalsFood/Other If yes, please specify Please mark (X) your response if you have or have had any of the following diseases or problems. Heart murmurMitral valve prolapseArtificial heart valvesRheumatic feverCardiovascular diseaseAnginaArteriosclerosisCongestive heart failureCoronary artery diseaseDamaged heart valvesHeart attackLow blood pressureHigh blood pressureCongenital heart defectsPacemakerRheumatic heart diseaseAbnormal bleedingAnemiaBlood transfusionHemophiliaAIDS or HIV infectionArthritisAutoimmune diseaseRheumatoid arthritisSystematic lupus erythematosusAsthmaBronchitisEmphysemaSinus troubleTuberculosisCancer/Chemotherapy/Radiation treatmentChest pain upon exertionChronic painDiabetes type I or type IIEating disorderMalnutritionGastrointestinal diseaseGE Reflux/persistent heartburnUlcersThyroid problemsStrokeGlaucomaHepatitis, jaundice, or liver diseaseEpilepsyFainting spells/seizuresNeurological disordersGag Reflex SensitivitySleep disorderMental health disordersRecurrent infectionsKidney problemsNight sweatsOsteoporosisPersistent swollen glands in neckSevere headche/migrainesSevere/rapid weight lossSTDs/STIsExcessive urinationADDADHDSensory Processing DisorderOral Sensory Sensitivity If “Blood transfusion”, date If “Neurological disorders”, please specify If “Mental health disorders”, please specify If “Recurrent infections”, type of infection Has a physician recommended that you take antibiotics prior to your dental treatment? YesNo Do you have any disease, condition, or problem not listed above that we should know about? YesNo If yes, please explain PHARMACY INFORMATION Pharmacy Name Pharmacy Phone Pharmacy Address SIGNATURE NOTE: Both Doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment. I certify that I have read and understand the above and that the information given on this form is accurate. I understand the importance of a truthful health history and that my doctor and their staff will use this information for treating me. I acknowledge that my questions, if any, about inquiries set forth above have been answered to my satisfaction. I will not hold my doctor, or any other member of their staff, responsible for any action they take or do not take because of errors or omissions that I may have made in the completion of this form. Name of Patient/Legal Guardian Date Electronic Signature (type full name) I confirm the information provided is accurate and I consent to electronic signature. All parties involved agree that this document may be signed electronically for the purposes of validity, enforceability, and admissibility. FOR COMPLETION BY OFFICE Comments:
