Welcome!
Please enter the patient's name below:
First Name
Last Name
Dental Health History
Date of last health care exam
What was this exam for?
Have you been hospitalized in the last 5 years?
Yes
No
Explain:
Health Conditions
For the following questions, select Yes or No. Your answers are for our records only and will be confidential. Please note that during your initial visit you will be asked some questions about your response. Our team may ask additional questions concerning your health
Heart Murmur (mitral valve prolapse)
Yes
No
Psychosis
Yes
No
Anemia
Yes
No
Sore/Enlarged Lymph Nodes
Yes
No
Diabetes
Yes
No
Previous Biopsies
Yes
No
Epilepsy
Yes
No
Slow-Healing Mouth Sores
Yes
No
Hepatitis, Any Form
Yes
No
Other Infections
Yes
No
Rheumatic Fever
Yes
No
Recurrent Illnesses
Yes
No
Asthma
Yes
No
Joint Replacement
Yes
No
HIV Positive or AIDS Related Complex
Yes
No
Glaucoma
Yes
No
Emphysema or other Respiratory Illnesses
Yes
No
Abnormal Bleeding From a Cut
Yes
No
Abnormal Heart Condition
Yes
No
Liver Disease (including Jaundice)
Yes
No
Kidney Disease
Yes
No
Unintentional Weight Loss/Gain
Yes
No
Heart (Surgery, Disease, Attack)
Yes
No
Latex Sensitivity
Yes
No
Venereal Disease
Yes
No
Other
Yes
No
If other, please explain:
Are you required to Pre-Medicate before dental treatment?
Yes
No
If yes, what medication:
Female Patients
Are you a female patient?
Yes
No
Other Medical Conditions
Abnormal Blood Pressure?
Yes
No
If yes, what is it usually:
Are you allergic or have you had a reaction to:
Local anesthetics
Yes
No
Penicillin or other antibiotics
Yes
No
Aspirin
Yes
No
Codeine, valium or other sedatives
Yes
No
Other
Yes
No
If other, please list:
Are you a smoker?
Yes
No
If so, how much do you smoke per day?
Please list any medications you are currently taking:
Are you taking Tagamet (Cimetidine)?
Yes
No
If yes, how often?
Do you take Antacids?
Yes
No
If yes, how often do you take Antacids?
Are you taking herbal supplements/medications?
Yes
No
If yes, how often are you taking herbal supplements/medications?
Diet
Are you on a Restricted Diet?
Yes
No
If yes, how many meals a day?
Do you have any Food Allergies?
Yes
No
If yes, to what?
Sugar in your diet:
None
Slight
Moderate
High
Headaches, TMJ pain
Do you have Severe Migranes: 15 days/month, 4 hrs minimum?
Yes
No
Do you have Occasional or Mild Migrane headaches?
Yes
No
Do you have TMJ pain?
Yes
No
Do you use a Night Guard?
Yes
No
Have you received any Botox or Dermal Fillers in the past?
Yes
No
Any other issues regarding your medical or dental history?
Dental management special requests:
Signature
Patient Signature
Clear
Date today:
IN OFFICE USE ONLY
Are you a member of staff?
Yes
No