Health History Form

Welcome to our office! We are excited to have you as a new patient.

Please fill out all four sections of the Health History Form by following the links below. Click the Submit button on the Signature page when you're finished.

Personal Information

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Oral Hygiene

How often do you brush your teeth?

When you brush your teeth in the morning, do you normally...

What type of toothbrush do you use?

How often do you floss your teeth?

Do you use a mouthwash regularly?

Which brand of mouthwash do you use?

Do you get headaches frequently?

Please check all the following foods you consume regularly

Medical History

Are you taking any medication?

Allergies

  • Asprin
  • Barbiturates
  • Codeine
  • Iodine
  • Latex
  • Local Anesthetic
  • Metals
  • Penicillin
  • Pine Nuts
  • Sulfa

Medical Treatments

Do you have/previously had, currently taking/previously taken medication for any of the following:

  • Alcoholism
  • Anemia
  • Angina Pectoris
  • Arthritis
  • Artificial Joint
  • Asthma
  • Bisphosphonate
  • Blood Transfusion
  • Bruise Easily
  • Chest Pain
  • Cold Sores
  • Persistent Cough
  • Diabetes
  • Drug Addiction
  • Eating Disorder
  • Emphysema
  • Epilepsy or Seizures
  • Fainting/Dizzy Spells
  • Fosomax
  • Glaucoma
  • Heart Problems
  • Heart Surgery
  • Hemophilia
  • Hepatits A/B/C
  • High Blood Pressure
  • HIV+
  • Hives or Skin Rash
  • Implant (any)
  • Kidney Trouble
  • Jaundice
  • Lung Disease
  • Mental Retardation
  • Oral Herpes
  • Psychiatric Treatment
  • Radiation/Chemo
  • Shortness of Breath
  • Sickle Cell Disease
  • Sinus Trouble
  • Steriod Treatment
  • Thyroid Disease
  • Tobacco Use
  • Transplant (any)
  • Tuberculosis (TB)
  • Ulcers

Please indicate any jaw related problems below

Please indicate if you are currently experiencing

Please indicate any sensitivity to

Have you ever had a bad experience in a dental office?

Do you feel nervous about having dental treatment?

Is there anything you dislike about your smile?

Is there anything you would like to speak to the doctor about in private?

Have you been hospitalized within the past two years?

Have you taken any medication or drugs in the past two years?

Are you taking any vitamins or herbal supplements?

Have you had excessive bleeding requiring special treatment?

Are there any sores or growths in your mouth now?

Have you been told you have gum problems?

Have you ever seen a periodontist (gum specialist)?

(Women) Are you pregnant?

(Women) Are you breastfeeding?

(Women) Are you taking oral contraceptives?

Signature

I certify I have read and understand information on this form. The questions have been accurately answered. I understand that providing incorrect information can be dangereous to my health. I authorize the dentist to release any information including the diagnosis and the records of any treatment or examination rendered to me or my child druing the period of such dental care to third party payors and/or healthcare practitioners. I authorize and request my insurance company to pay directly to the dentist the benefits otherwise payable to me. I understand that my insurance carrier may pay less than the actual bill for rendered services. I agree to be responsible for payment of all services rendered on my behalf or my dependents behalf. I consent to (TCPA of 1991) being contacted on my cell phone number (provided by me) regarding all issues. I acknowledge that I have received and read a copy of the Dental Materials Fact Sheet , a copy of the Notice of Privacy Practices Sheet and the Financial and Appointment Policy Sheet . (Links open in new tabs.)

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    and let Denise know at the front desk that your Health History Form is incomplete.