Patient Health History Form

Patient Information

Name *

Date *

Date of Birth *

Height

Weight

Sex *

Male

Female

Other

If other, please describe

An accurate and complete health history will assist in coordinating your dental care. Please speak with the doctor or staff if there are any questions about this form.

Dental History

Please describe your current dental health

Excellent

Good

Fair

Poor

Have there been any changes in your dental health in the past year?

Yes

If yes, please describe

Are you having any dental discomfort at this time?

Yes

If yes, please describe

Have you had any adverse effects from dental treatment?

Yes

If yes, please describe

Medical History

Please describe your current overall health

Excellent

Good

Fair

Poor

Have there been any changes in your general health in the past year?

Yes

If yes, please describe

Are you now under a doctor’s care for a medical condition?

Yes

If yes, please describe

Have you ever been hospitalized or had a serious illness?

Yes

If yes, please describe

Have you ever had surgery?

Yes

If yes, please describe

Medical History (Continued)

Congenital heart or cardiovascular disease (heart attack, murmur, CAD, chest pain, high/low blood pressure, stroke, irregular heartbeat, heart surgery, pacemaker)

Yes

Lung disease (asthma, emphysema, COPD, chronic cough, bronchitis, pneumonia, tuberculosis, shortness of breath, chest pain)

Yes

Bleeding disorder, anemia, bleeding tendency, blood transfusion, bruise easily

Yes

Implants placed anywhere in the body (heart valve, pacemaker, hip, knee)

Yes

Medical History (Continued)

Radiation to the jaws or head and neck area

Yes

If yes, please describe

Cancer

Yes

If yes, type

Osteoporosis or osteopenia

Yes

Diagnosis date

Treatment

Do you have any other medical conditions that are important for your doctor to know about?

Yes

If yes, please describe

Medications

Are you currently prescribed or taking any of the following?

Please list the specific medications indicated above and/or any other medications not listed above that you are currently taking. Please include all prescription medications, diet drugs, over the counter medications, herbal or holistic remedies, vitamins, or minerals:

Medication Name 1

Dose / Frequency

Medication Name 2

Dose / Frequency

Medication Name 3

Dose / Frequency

Medication Name 4

Dose / Frequency

Medication Name 5

Dose / Frequency

Medication Name 6

Dose / Frequency

Medication Name 7

Dose / Frequency

Medication Name 8

Dose / Frequency

Medication Name 9

Dose / Frequency

Medication Name 10

Dose / Frequency

Anesthesia History

Have you had any problems associated with local anesthesia, general anesthesia, and/or intravenous sedation?

Yes

If yes, please describe

Female Patients

Are you pregnant?

Yes

Is there any chance you might be pregnant?

Yes

Do you wish to talk to the doctor about anything in private?

Yes

Signature & Acknowledgment

I understand the importance of a truthful and complete health history to assist my doctor(s) in providing coordinated care. To the best of my knowledge, the above information is complete and correct.

Patient Name (Print) *

Patient/Guardian Signature *

Date *

Name Validation *

Patient Health History Form

Medical History (Continued)

Medical History (Continued)

Medications

Allergies

Anesthesia History

Female Patients

Social History

Signature & Acknowledgment

Signature