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Health History Form

E-mail:

As required by law, our office adheres to written polices and procedures to protect the privacy of information about you that we create, receive or maintain. Your answers are for our records only and will be kept confidential subject to applicable laws. Please note that you will be asked some questions about your responses to this questionnaire and there may be additional questions concerning your health. This information is vital to allow us to provide appropriate care for you. This office does not use this information to discriminate.

Name:

Address:

Occupation / Phone:

Phone:

Height / Weight / DOB:

SS# or Patient ID# / Sex:

M F

Emergency Contact:

Relationship:

Home/Cell:

If you are completing this form for another person, what is your relationship to that person?

Your name:

Relationship:

Date of your last dental exam / x-rays:

What was done at that time?

What is the reason for your dental visit today?

How do you feel about your smile?

Joint Replacement

Have you had an orthopedic total joint (hip, knee, elbow, finger) replacement?

Yes No DK

If yes: Date:

Have you had any complications?

Are you taking or are you being scheduled to begin taking either of these medications: alendronate (Fosamax®) or risedronate (Actonel®) for osteoporosis or Paget’s disease?

Yes No DK

Since 2001, were you treated or are you presently scheduled to begin treatment with intravenous bisphosphonates (Aredia® or Zometa®) for bone pain, hypercalcemia or skeletal complications resulting from Paget’s disease, multiple myeloma or metastatic cancer?

Yes No DK

If yes, date treatment began?

Allergies. Are you allergic to or have you had a reaction to (for all YES responses, specify type of reaction):

WOMEN ONLY.

Are you pregnant?

Yes No DK

If yes, number of weeks:

Taking birth control pills or hormonal replacement?

Yes No DK

Nursing?

Yes No DK

Please mark (✔) your response to indicate if you have or have not had any of the following diseases or problems.
(Check DK if you Don't Know the answer to the question)

Has a physician or previous dentist recommended that you take antibiotics prior to your dental treatment?

Yes No DK

Name of physician or dentist making recommendation:

Phone:

Do you have any disease, condition, or problem not listed above that you think I should know about?

Yes No DK

If yes, please explain:

Conclusion

NOTE: Both Doctor and Patient are encouraged to discuss any and all relevant patient health issues prior to treatment.

I certify that I have read and understand the above and that the information given on this form is accurate. I understand the importance of a truthful health history and that my dentist and his/her staff will rely on this information for treating me. I acknowledge that my questions, if any, about inquiries set forth above have been answered to my satisfaction. I will not hold my dentist, or any other member of his/her staff, responsible for any action they take or do not take because of errors or omissions that I may have made in the completion of this form.

I understand that responsibility for payment for dental services provided in this office for myself or my dependant is mine. Unless prior special arrangements are made, accounts are to be paid on the date on which service is provided. I hereby authorize that the payment due from any insurance company be paid directly to this office. In the event of a default in payment, patient or party responsible agrees to pay any and all costs of suit, collection, and attorney’s fees. I have authorized you or your agents to check with any credit bureau and to verify my employment or insurance coverage.

Signature of Patient/Legal Guardian:

Click to Sign

Date:-------------

truForm by PBHS

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Demographic Info

Health History Form

Do you have any of the following diseases or problems:

Dental Information

Dental Information

Medical Information

Medical Information

Joint Replacement

Allergies

WOMEN ONLY.

Medical Info Cont.

Conclusion

Conclusion

Click to Sign

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Main Header

Demographic Info

Health History Form

Do you have any of the following diseases or problems:

Dental Information

Dental Information

Medical Information

Medical Information

Joint Replacement

Allergies

WOMEN ONLY.

Medical Info Cont.

Conclusion

Conclusion

Click to Sign

PBHS truForm is best utilized in portrait mode.

Please rotate your device to portrait orientation to begin.

You are in Private Browsing mode.

This form requires that you disable private browsing to continue. Please open a new browser window and reload the form.

This form requires that you disable private browsing to continue.
Please open a new browser window and reload the form.