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Health History Form
Dental Information
Medical Information

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Health History Form

Patient Information

As required by law, our office adheres to written policies 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

First Name

M.I.

Last Name

Phone Number: Include area Code

Home Phone

Business / Cell Phone

Email Address

Mailing Address

Street Address

City

State

Zip (Postal Code)

Sex

Female Male

Occupation:

Occupaton

What is your height?

Height

What is your weight?

Weight

Date of birth / Social Security Number or Patient ID:

Birth Date

Social Security Number or Patient ID

Emergency Contact/ Relatoinhip:

Name

Relationship

Phone Number:

Home Phone

Cell Phone

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

Your Name / Relationship:

Name of Person Completing this Form

Relation

Do you have any of the following diseases or problems: (Check DK if you Don't Know the answer to the question)

Active Tuberculosis

Yes No Don't Know

Persistent cough greater than a 3 week duration

Yes No Don't Know

Cough that produces blood

Yes No Don't Know

Been exposed to anyone with tuberculosis

Yes No Don't Know

If you answer yes to any of the 4 items above, please stop and return this form to the receptionist.

Dental Information

For the following questions, please mark (X) your responses to the following questions.

Do your gums bleed when you brush or floss?

Yes No Don't Know

Are your teeth sensitive to cold, hot, sweets or pressure?

Yes No Don't Know

Does food or floss catch between your teeth?

Yes No Don't Know

Is your mouth dry

Yes No Don't Know

Have you had any periodontal (gum) treatments?

Yes No Don't Know

Have you ever had orthodontic (braces) treatment?

Yes No Don't Know

Have you had any problems associated with previous dental treatment?

Yes No Don't Know

Is your home water supply fluoridated?

Yes No Don't Know

Do you drink bottled or filtered water?

Yes No Don't Know

If yes, how often?

Daily Weekly Occasionally

Are you currently experiencing dental pain or discomfort?

Yes No Don't Know

Do you have earaches or neck pains

Yes No Don't Know

Do you have any clicking, popping or discomfort in the jaw?

Yes No Don't Know

Do you brux or grind your teeth?

Yes No Don't Know

Do you have sores or ulcers in your mouth?

Yes No Don't Know

Do you wear dentures or partials?

Yes No Don't Know

Do you participate in active recreational activities?

Yes No Don't Know

Have you ever had a serious injury to your head or mouth?

Yes No Don't Know

Date of your last dental exam:

Date of Last Dental Exam

What was done at that time?

What Was Done

Date of last dental x-rays

Last Dental X-ray

What is the reason for your dental visit today?

Reason for Visit

How do you feel about your smile?

how do you feel about your smile

Medical Information

Medical Information Please mark (X) your response to indicate if you have or have not had any of the following diseases or problems

Are you now under the care of a physician?

Yes No Don't Know

Physician Name / Phone:

Physician's Name

Phone Number

Physician's Address

Address/City/State/Zip

Are you in good health?

Yes No Don't Know

Has there been any change in your general health within the past year

Yes No Don't Know

If yes, what condition is being treated?

Condition Being Treated

Date of last physical exam:

Physical Exam Date

Have you had a serious illness, operation or been hospitalized in the past 5 years?

Yes No Don't Know

If yes, what was the illness or problem?

Reason

Are you taking or have you recently taken any prescription or over the counter Medicine(s)?

Yes No Don't Know

If so, please list all, including vitamins, natural or herbal preparations and/or diet supplements:

Please List All Medicaitons and Supplements

Do you wear contact lenses?

Yes No Don't Know

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

Yes No Don't Know

Date:

Date

If yes, have you had any complications?

Please Explain

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

Yes No Don't Know

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

Yes No Don't Know

If yes, Date Tratment began:

Date Treatment Began

Do you use controlled substances (drugs)?

Yes No Don't Know

Do you use tobacco (smoking, snuff, chew, bidis)?

Yes No Don't Know

If so, how interested are you in stopping?

Very Somewhat Not Interested

Do you drink alcoholic beverages?

Yes No Don't Know

If yes, how much alcohol did you drink in the last 24 hours?

how much in last 24 hours

If yes, how much do you typically drink In a week?

how much in a typical week

Women Only

Are you Pregnant?

Yes No Don't Know

Number of weeks :

How many weeks pregnant are you

Are you taking birth control pills or hormonal replacement?

Yes No Don't Know

Are You Nursing?

Yes No Don't Know

Allergies

Are you allergic to or have you had a reaction to:
To all yes responses, specify the type of reaction

Local anesthetics

Yes No Don't Know

Type of Reaction:

Type of Reaction

Aspirin

Yes No Don't Know

Type of Reaction

Penicillin or other Antibiotics

Yes No Don't Know

Type of Reaction

Sulfa drugs

Yes No Don't Know

Type of Reaction

Barbiturates, sedatives, or sleeping pills

Yes No Don't Know

Type of Reaction

Codeine or other Narcotics

Yes No Don't Know

Type of Reaction

Metals

Yes No Don't Know

Type of Reaction

Latex (rubber)

Yes No Don't Know

Type of Reaction

Iodine

Yes No Don't Know

Type of Reaction

Hay fever/Seasonal

Yes No Don't Know

Type of Reaction

Animals

Yes No Don't Know

Type of Reaction

Food

Yes No Don't Know

Type of Reaction

Other

Yes No Don't Know

Type of Reaction

Medical Information Continued

Please mark (X) your response to indicate if you have or have not had any of the following diseases or problems.

Artificial (prosthetic) heart valve

Yes No Don't Know

Previous infective endocarditis

Yes No Don't Know

Damaged valves in transplanted heart

Yes No Don't Know

Congenital heart disease (CHD)

Unrepaired, cyanotic CHD

Yes No Don't Know

Repaired (completely) in last 6 months

Yes No Don't Know

Repaired CHD with residual defects

Yes No Don't Know

Except for the conditions listed above, antibiotic prophylaxis is no longer recommended for any other form of CHD.

Cardiovascular Disease

Yes No Don't Know

Angina

Yes No Don't Know

Arteriosclerosis

Yes No Don't Know

Congestive heart failure

Yes No Don't Know

Damaged heart valves

Yes No Don't Know

Heart attack

Yes No Don't Know

Heart murmur

Yes No Don't Know

Low Blood Pressure

Yes No Don't Know

High blood pressure

Yes No Don't Know

Other congenital heart defects

Yes No Don't Know

Mitral valve prolapse

Yes No Don't Know

Pacemaker

Yes No Don't Know

Rheumatic fever

Yes No Don't Know

Rheumatic heart disease

Yes No Don't Know

Abnormal bleeding

Yes No Don't Know

Anemia

Yes No Don't Know

Blood Transfusion

Yes No Don't Know

If yes, date:

date of transfusion

Hemophilia

Yes No Don't Know

AIDS or HIV infection

Yes No Don't Know

Arthritis

Yes No Don't Know

Autoimmune disease

Yes No Don't Know

Rheumatoid arthritis

Yes No Don't Know

Systemic lupus erythematosus

Yes No Don't Know

Column2

Asthma

Yes No Don't Know

Bronchitis

Yes No Don't Know

Emphysema

Yes No Don't Know

Sinus trouble

Yes No Don't Know

Tuberculosis

Yes No Don't Know

Cancer/Chemotherapy/Radiation Treatment

Yes No Don't Know

Chest pain upon exertion

Yes No Don't Know

Chronic pain

Yes No Don't Know

Diabetes Type I or II

YEs No Don't Know

Eating Disorder

Yes No Don't Know

Malnutrition

Yes No Don't Know

Gastrointestinal disease

Yes No Don't Know

G.E Reflux/persistent heartburn

Yes No Don't Know

Ulcers

Yes No Don't Know

Thyroid problems

Yes No Don't Know

Stroke

Yes No Don't Know

Glaucoma

Yes No Don't Know

Hepatitis, Jaundice or Liver disease

Yes False Don't Know

Epilepsy

Yes No Don't Know

Fainting spells or seizures

Yes No Don't Know

Neurological disorders

Yes No Don't Know

If yes, specify:

Please Specify

Sleep disorder

Yes No dk

Mental Health Disorders

Yes No Don't Know

If yes, specify

please specify

Recurrent Infections

Yes No Don't Know

Type of infection:

type of infection

Kidney Problems

Yes No Don't Know

Nightweats

Yes No Don't Know

Osteoporosis

Yes No Don't Know

Persistent swollen glands in neck

Yes No Don't Know

Severe Headaches/Migraines

Yes False Don't Know

Severe or rapid weight loss

Yes No Don't Know

Sexually transmited disease

Yes No Don't Know

Excessive Urination

Yes No Don't Know

Medical Information Continued

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

Yes No Don't Know

Name of physician or dentist making recommendation / Phone:

Physician's Name

Phone

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

Yes No Don't Know

Please explain:

Please Explain

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.

Signature label

Click to Sign

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

Comments:

Comments

truForm by PBHS

Main Header

Health History Form

Patient Information

Dental Information

Dental Information

Medical Information

Medical Information

Women Only

Allergies

Medical Information Continued

Column2

Medical Information Continued

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Main Header

Health History Form

Patient Information

Dental Information

Dental Information

Medical Information

Medical Information

Women Only

Allergies

Medical Information Continued

Column2

Medical Information Continued

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.

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