Form:
Health History
Page 1
Confirm
Patient Information
FIRST Name
LAST Name
MI
Date of Birth
Pronouns
Dental Information
NO to All
Please choose YES or NO for all questions below.
Do your gums bleed when you brush or floss?
YES
NO
Are your teeth sensitive to cold, hot, sweets or pressure?
YES
NO
Is your mouth dry?
YES
NO
Have you had any periodontal (gum) treatments?
YES
NO
Have you ever had orthodontic (braces) treatment?
YES
NO
Have you had any problems associated with previous dental treatment?
YES
NO
Is your home water supply fluoridated?
YES
NO
Do you drink bottled or filtered water?
YES
NO
Are you currently experiencing dental pain or discomfort?
YES
NO
Do you have earaches or neck pains?
YES
NO
Do you have any clicking, popping, or discomfort in the jaw?
YES
NO
Do you brux or grind your teeth?
YES
NO
Do you have sores or ulcers in your mouth?
YES
NO
Have you ever had a serious injury to your head or mouth?
YES
NO
Date of your last dental exam:
What was done at that time?
Date of last dental x-rays:
What is the reason for your dental visit today?
How do you feel about your smile?
Medical Information
Are you now under the care of a physician?
YES
NO
Physician Name:
Physician Phone Number (include area code)
Address/City/State/Zip:
Are you in good health?
YES
NO
Has there been any change in your general health within the past year?
YES
NO
Date of last physical exam:
Have you had a serious illness, operation or been hospitalized in the past 5 years? If yes, what was the illness or problem?
YES
NO
Are you taking or have you recently taken any prescription or over the counter medicine(s)? If so, please list all, including vitamins, natural or herbal preparations and/or dietary supplements:
YES
NO
Joint Replacement: Have you had an orthopedic total joint (hip, knee, elbow, finger) replacement? If yes, please state the date of replacement and any complications:
YES
NO
Are you taking or scheduled to begin taking an antiresorptive agent (like Fosamax, Actonel, Atelvia, Boniva, Reclast, Prolia) for osteoporosis or Paget's disease?
YES
NO
Do you use controlled substances (drugs)?
YES
NO
Do you use tobacco (smoking, snuff, chew, bidis)?
YES
NO
If so, how interested are you in stopping? (Select one)
Very
Somewhat
Not Interested
Do you drink alcoholic beverages?
YES
NO
If yes, how much alcohol did you drink in the last 24 hours?
If yes, how much do you typically drink in a week?
Allergies. Are you allergic to or have you had a reaction to: To all "yes" responses, specify type of reaction
Local anesthetics
YES
NO
Aspirin
YES
NO
Penicillin or other antibiotics
YES
NO
Barbiturates, sedatives, or sleeping pills
YES
NO
Sulfa drug
YES
NO
Codeine or other narcotics
YES
NO
Metals
YES
NO
Latex (rubber)
YES
NO
Iodine
YES
NO
Hay fever/seasonal
YES
NO
Animals
YES
NO
Food
YES
NO
Other
YES
NO
Medical Conditions
Artificial (prosthetic) heart valve
YES
NO
Previous infective endocarditis
YES
NO
Damaged valves in transplanted heart
YES
NO
Unrepaired, cyanotic Congenital Heart Disease (CHD)
YES
NO
Repaired (completely) CHD in last 6 months
YES
NO
Repaired CHD with residual defects
YES
NO
Cardiovascular Disease
YES
NO
Angina
YES
NO
Arteriosclerosis
YES
NO
Congestive heart failure
YES
NO
Damaged heart valves
YES
NO
Heart attack
YES
NO
Heart murmur
YES
NO
Low blood pressure
YES
NO
High blood pressure
YES
NO
Other congenital heart defects
YES
NO
Mitral valve prolapse
YES
NO
Pacemaker
YES
NO
Rheumatic fever
YES
NO
Rheumatic heart disease
YES
NO
Abnormal bleeding
YES
NO
Anemia
YES
NO
Blood transfusion. If yes, date:
YES
NO
Hemophilia
YES
NO
AIDS or HIV infection
YES
NO
Arthritis
YES
NO
Autoimmune disease
YES
NO
Rheumatoid arthritis
YES
NO
Systemic lupus erythematosus
YES
NO
Asthma
YES
NO
Bronchitis
YES
NO
Emphysema
YES
NO
Sinus trouble
YES
NO
Tuberculosis
YES
NO
Cancer/Chemotherapy/Radiation Treatment
YES
NO
Chest pain upon exertion
YES
NO
Chronic pain
YES
NO
Diabetes Type I or II
YES
NO
Eating disorder
YES
NO
Malnutrition
YES
NO
Gastrointestinal disease
YES
NO
G.E. Reflux/persistent heartburn
YES
NO
Ulcers
YES
NO
Thyroid problems
YES
NO
Stroke
YES
NO
Glaucoma
YES
NO
Hepatitis, jaundice, or liver disease
YES
NO
Epilepsy
YES
NO
Fainting spells or seizures
YES
NO
Neurological disorders
YES
NO
Sleep disorders
YES
NO
Do you snore?
YES
NO
Mental health disorders
YES
NO
Recurrent Infections
YES
NO
Kidney problems
YES
NO
Night sweats
YES
NO
Osteoporosis
YES
NO
Persistent swollen glands in neck
YES
NO
Severe headaches/migraines
YES
NO
Severe or rapid weight loss
YES
NO
Sexually transmitted disease
YES
NO
Excessive urination
YES
NO
ADD/ADHD
YES
NO
Autism
YES
NO
Alzheimer's
YES
NO
Has a physician or previous dentist recommended that you take antibiotics prior to your dental treatment?
YES
NO
Name of physician or dentist making recommendation
Do you have any disease, condition, or problem not listed above that you think I should know about?
YES
NO
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