Patient Health History Form

About You:

Your Name

First Last

Today's Date(Required)

Gender

Marital Status

Single

Married

Divorced

Widowed

Birth Date(Required)

Social Security Number

Drivers License Number

Home Address

Employer

Work Address

Occupation

Who Referred You

Family Members Seen By Us

Special Interests or Hobbies

Dental Insurance

Group Number

Effective Date

Home Phone

Cell Phone

Email Address

Best Time To Call

Where Should We Contact You

Emergency Contact

Emergency Contact Name

First Last

Emergency Contact Phone Number

Relation

Spouse/Partner/Significant Other Information:

His or Her Name

First Last

Employer

Home Phone

Cell Phone

Person Financially Responsible:

Name

First Last

Address

Home Phone

Cell Phone

Birth Date(Required)

Hidden

Social Security Number

Insurance and Financial Information

Insurance Coverage

Yes

Insurance Company Name

Insurance Address

Insurance Phone

Subscriber's Name

Patienship Relationship to Subscriber

Self

Spouce

Dependent

Subscriber's Birth Date

Subscriber's SSN / ID #

Group / Program Number

Employer (If different from above)

Employer's Address

Secondary Coverage

Yes

Insurance Company Name

Insurance Address

Insurance Phone

Subscriber's Name

Patienship Relationship to Subscriber

Self

Spouce

Dependent

Subscriber's Birth Date

Subscriber's SSN / ID #

Group / Program Number

Employer (If different from above)

Employer's Address

I give my consent to bill my insurance and to providing any necessary documents and or records needed(Required)

Yes

Medical History:

Your current physical health is

Excellent

Good

Fair

Poor

Are you currently under the care of a physician?

Yes

If Yes, Please Explain:

Name of Physician:

Phone Number

Date of Last Physical Exam:

Are you taking any prescription medications?

Yes

Name of Medication(s):

Purpose

Do you smoke or use chewing tobacco?

Yes

If Yes, How Much Per Day

For Women:

Are you pregnant?

Yes

If yes, how many months?

Are you nursing?

Yes

Are you taking birth control pills?

Yes

Do you plan on becoming pregnant in the near future and when?

Medical Problems:

Have you had any serious medical problems within the past 5 years?

Yes

If yes, please explain:

Have you ever had, or been treated for any of the following diseases or medical problems?

Heart Attack/Stroke

Yes

Hepatitis/Jaundice

Yes

Epilepsy/Seizures/Fainting

Yes

Cancer/Chemotherapy/Radiation

Yes

Psychiatric problems

Yes

Tuberculosis

Yes

Anemia

Yes

Artificial Bones/Joints/Valves

Yes

Blood Transfusion

Yes

HIV+/AIDS

Yes

Colitis

Yes

Heart Murmur

Yes

Rheumatic Fever

Yes

High/Low Blood Pressure

Yes

Abnormal Bleeding

Yes

Kidney Problems

Yes

Diabetes

Yes

Drug/Alcohol Abuse

Yes

Arthritis

Yes

Asthma/Breathing Problems

Yes

Herpes/Fever Blister

Yes

Glaucoma

Yes

Migraine Headaches

Yes

Heart Defects

Yes

Pacemaker

Yes

Hemophilia

Yes

MitralValveProlapse

Yes

Thyroid Problems

Yes

Liver Disease

Yes

Venereal Disease

Yes

Emphysema

Yes

Shingles

Yes

Sickle Cell Disease

Yes

Sinus Problem

Yes

Sleep Apnea

Have you been diagnosed with Obstructive Sleep Apnea?

Yes

Do you snore?

Yes

Do you have fatigue?

Yes

Do you have an interest in Oral Appliances?

Yes

Are you allergic to any of the following?

Aspirin

Yes

Codeine

Yes

Dental Anesthetics

Yes

Sulfa

Yes

Latex

Yes

Penicillin

Yes

Tetracycline

Yes

Other

Our Office is committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC, and the ADA.

DENTAL QUESTIONNAIRE

Do you need to be pre-medicated before dental treatment (history of heart murmur, bacterial endocarditis, mitral valve prolapse, etc., presence of metal plates, pins and rods in the body)?

Yes

Why have you come to the dentist today?(Required)

These are the things that are important to me about my dental health:*(Required)

Approx date of last dental visit(Required)

Previous dentist's name

First Last

Phone Number

Are you currently in pain or discomfort?

Yes

If yes, please explain:

Have you ever had any serious problems with previous dental work?

Yes

If yes, please explain:

Does dental treatment make you nervous?

Have you ever been treated for periodontal disease (gum disease, pyorrhea, trench mouth)?

Yes

Do you have problems with bad breath?

Yes

Do your gums ever bleed when you brush or floss?

Yes

If you could easily and safely whiten your teeth, would you be interested?

Yes