Items marked with asterisk (*) must be completed.

First Name

Middle Name

Last Name

I prefer to be called (Nickname)

Birth Date (MM-DD-YYYY)

Social Security Number (U.S. only)

Home Phone

Street

City

State/Province

Zip/Postal Code

Work Phone

Cell/Other Phone

Email Address

Gender

Male

Female

If patient is a minor, give parent's or guardian's name

Whom may we thank for referring you to our office?

Responsible Party Information

Dental Insurance Information

Do you have Dental Insurance?

Emergency Information

Person to contact in case of emergency

Street

City

State/Province

Zip/Postal Code

Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry that you will be receiving. Thank you for answering the following questions.

Are you allergic to or have you had reactions to any of the following

Local Anesthetics like Novocain

Yes

Penicillin or Other Antibiotics

Yes

Sulfa Drugs

Yes

Barbiturates, Sedatives or Sleeping Pills

Yes

Aspirin

Yes

Iodine

Yes

Any Metals (E.G., Nickel, Mercury, Etc.)

Yes

Latex/Rubber

Yes

Please check any of the following that you have had or currently have:

Abnormal bleeding/Hemophilia

Yes

Anemia

Yes

Arthritis

Yes

Asthma or Hay fever

Yes

Congenital Heart Defect

Yes

Diabetes

Yes

Fainting or Dizzy Spells

Yes

Epilepsy or Seizures

Yes

Heart Problems

Yes

Heart Murmur

Yes

Hepatitis/Liver Problems

Yes

Herpes

Yes

High/Low Blood Pressure

Yes

HIV/Aids

Yes

Kidney Problems

Yes

High Cholesterol

Yes

Pneumonia

Yes

Nervous Disorders

Yes

Radiation/Chemotherapy

Yes

Rheumatic Fever

Yes

Tuberculosis

Yes

Tumor or Cancer

Yes

Scarlet Fever

Yes

Chest Pain

Yes

Shortness of Breath

Yes

Pacemaker

Yes

Heart Surgery

Yes

Swelling of Feet, Ankles, Hands

Yes

Stroke

Yes

Sinus Trouble

Yes

Lung or Breathing Problems

Yes

Hives or Skin Rash

Yes

Thyroid Problems

Yes

Allergies

Yes

Joint Replacement or Implant

Yes

Stomach ulcer

Yes

Persistant Cough

Yes

Sexually Transmitted Disease

Yes

Glaucoma

Yes

Tonsillitis

Yes

Mental Health Care

Yes

Back Problems

Yes

Chemical Dependency

Yes

Mitral Valve Prolapse

Yes

Cortisone Treatment

Yes

Cold Sores/ Fever Blisters

Yes

Hypoglycemia

Yes

Eating Disorders

Yes

1. Are you in good health

2. Have there been any changes in your general health within the past year

3. Date of your last physical exam

4. Physician's name, address and phone #

5. Are you now under the care of a physician?

6. Have you ever been hospitalized for any surgical operation or serious illness? If yes, please explain

7. Are you taking any medicines including non-prescription medicine? If yes, please list them

Street

City

State/Province

Zip/Postal Code

8. Have you had any abnormal bleeding?

Yes

9. Do you bruise easily?

Yes

10. Have you ever required a blood tranfusion?

Yes

11. Have you had a recent weight loss?

Yes

13. Have you ever taken Fosamax, Boniva, Actonel or any cancer medications?

Yes

14. Have you ever Viagra, Revatio, Cialis or Levitra in the last 24 hours?

Yes

15. Do you use tobacco?

Yes

16. Do you or have you used controlled substances?

Yes

17. Are you wearing contact lenses?

Yes

18. Do you have a persistent cough or throat clearing not associated with a known illness (lasting more than 3 weeks)?

Yes

19. Do you have any disease, condition or problem not listed above that you think we should know about.

Women, please answer the below questions

Are you pregnant or think you may be pregnant?

Yes

Are you nursing?

Yes

Are you taking birth control pills?

Yes

General Dentist

Date of Last Visit

Do your gums bleed while brushing or flossing?

Yes

Are your teeth sensitive to hot or cold liquids/foods?

Yes

Are your teeth sensitive to sweet or sour liquids/food?

Yes

Do you feel pain to any of your teeth?

Yes

Do you have any sores or lumps in or near your mouth?

Yes

Have you had any head, neck or jaw injuries?

Yes

Have you ever experienced any of the following problems in your jaw

Clicking

Yes

Pain (joint, ear, side of face)

Yes

Difficulty in opening or closing

Yes

Difficulty in chewing

Yes

Do you have frequent headaches?

Yes

Do you clench or grind your teeth?

Yes

Do you bite your lips or cheeks frequently?

Yes

Does food tend to become caught between your teeth?

Yes

Have you ever had periodontal treatment (gums)?

Yes

Have you ever had any difficult extractions in the past?

Yes

Ever worn a bite plate or other appliance?

Yes

Have you ever had any prolonged bleeding following extractions?

Yes

Do you wear dentures or partials? If yes, date of placement

Have you ever received oral hygiene instructions regarding the care of your teeth and gums?

If you could change ANYTHING about your smile, what would you change?

Reason for your visit with us

Have you had a complete series of dental films (x-rays) taken? If yes, When and where?

How often do you brush your teeth?

How often do you floss your teeth?

Is your drinking water fluoridated?

Yes

Do you snore at night?

Yes

Have you ever been diagnosed with sleep apnea? If yes, do you use a CPAP machine?

Yes

AUTHORIZATION AND RELEASE I certify that I have read and understand the above information to the best of my knowledge. The above questions have been accurately answered. I understand that providing incorrect information can be dangerous to my health. I authorize the dentist to release any information.

I certify that I have read and understand the above information to the best of my knowledge. The above questions have been accurately answered. I understand that providing incorrect information can be dangerous to my health. I authorize the dentist to release any information.

Health History Form

Patient Information

Address

Responsible Party Information

Dental Insurance Information

Emergency Information

Complete Address

Medical History

Are you allergic to or have you had reactions to any of the following

Please check any of the following that you have had or currently have:

Pharmacy used?

Women, please answer the below questions

Dental History

Have you ever experienced any of the following problems in your jaw

Thank You!