Patient Health History Form

Please fill out the form below prior to your first dental visit.

Name:
Address
City
State
Zip Code
Email
Home Phone
Work Phone
Mobile Phone
Date of Birth
Social Security No.
Sex
Marital Status:
Primary Dental Guarantor
Home Phone
Work Phone
Secondary Dental Guarantor
Home Phone
Work Phone
Physician Name
Physician Phone
Pharmacy
Pharmacy Phone
Referred by:
Height:
Weight:
Do you smoke or use tobacco?  Yes No
Have you ever had Botox or Dermal Filler before?  Yes No

In the following questions, please click yes or no. Do you have or have you had any of the following diseases or conditions?

 
• Allergies  Yes No
• Artificial Bones  Yes No
• Artificial Heart Valve  Yes No
• High Blood Pressure  Yes No
• HIV+ AIDS  Yes No
• Mitral Valve Prolapse  Yes No
• Pace Maker  Yes No
• Abnormal Bleeding  Yes No
• Alcohol Abuse  Yes No
• Anemia  Yes No
• Angina Pectoris  Yes No
• Arthritis  Yes No
• Asthma  Yes No
• Cancer- Chemotherapy  Yes No
• Colitis  Yes No
• Congenital Heart Defect  Yes No
• Diabetes  Yes No
• Difficulty Breathing  Yes No
• Drug Abuse  Yes No
• Emphysema  Yes No
• Epilepsy  Yes No
• Fainting Spells  Yes No
• Frequent Headaches  Yes No
• Glaucoma  Yes No
• Hay Fever  Yes No
• Heart Attack  Yes No
• Heart Surgery  Yes No
• Hemophilia  Yes No
• Hepatitis A  Yes No
• Hepatitis B  Yes No
• Kidney Problems  Yes No
• Liver Disease  Yes No
• Low Blood Pressure  Yes No
• Psychiatric Problems  Yes No
• Radiation Therapy  Yes No
• Rheumatic Fever  Yes No
• Seizures  Yes No
• Shingles  Yes No
• Sinus Problems  Yes No
• Stroke  Yes No
• Thyroid Problems  Yes No
• Tuberculosis  Yes No
• Ulcers  Yes No
• Venereal Disease  Yes No
• Other

Allergies

 
• Aspirin  Yes No
• Codeine  Yes No
• Dental Anesthetics  Yes No
• Erythromycin  Yes No
• Jewelry  Yes No
• Latex  Yes No
• Metals  Yes No
• Penicillin  Yes No
Other
List all the drugs or medications that you are taking:
Have you had any serious trouble associated with any previous dental treatment?  Yes No
If so, explain
Do you have any disease, condition, or problem not listed above
that you think this office should know about?
 Yes No
If so, explain
Have you had anything to eat or drink in the last 4 hours?  Yes No
Are you wearing removable dental appliances?  Yes No

If female please answer the following

Are you taking Birth Control Pills?  Yes No
Are you pregnant?  Yes No
If Yes, # of weeks
20. Are you nursing?  Yes No
   
Chief Dental Complaint  
I certify that I have read and understand the above. I acknowledge that my questions, if any, about the inquiries set forth above have been answered to my satisfaction. I will not hold my dentist, or any other member of his/her staff, responsible for any errors or omissions that I may have made in the completion of this form.