Health History Form

Today's Date:

Name:

Date of Birth:

I. Answer the following questions (Leave blank if you do not understand the question)

Is your general health good?

Yes

No

If NO, explain:

Has there been a change in your health within the last year?

Yes

No

If YES, explain:

Have you gone to the hospital or emergency room or had a serious illness in the last three years?

Yes

No

If YES, explain:

Are you being treated by a physician now?

Yes

No

If YES, explain:

Date of last medical exam:

Reason for exam:

Had problems with prior dental treatment?

Yes

No

If YES, explain:

Date of last dental exam:

Name of last treating dentist:

Are you in pain now?

Yes

No

If YES, explain:

II. Have you experienced any of the following?

III. Have you had or do you have any of the following?

This information will not be released unless specifically authorized by patient.

AIDS/HIV

Yes

No

Anxiety

Yes

No

Depression

Yes

No

Treatment for Emotional Condition

Yes

No

IV. Are you allergic to or have you had a reaction to any of the following?

Other:

V. Are you taking or have you taken any of the following in the last three months?

Recreational Drugs

Yes

No

Over-the-Counter Medicines

Yes

No

Weight Loss Medications

Yes

No

Cortico-Steroids

Yes

No

Tobacco in any Form

Yes

No

Alcohol

Yes

No

Bisphosphonate (Fosamax)

Yes

No

Antibiotics

Yes

No

Supplements

Yes

No

Aspirin

Yes

No

Please list all medications you are currently taking:

VI. Women Only

Are you or could you be pregnant?

Yes

No

If YES, what month?:

Are you nursing?

Yes

No

Are you taking birth control pills?

Yes

No

VII. All Patients

Do you have or have you had any other diseases or medical problems NOT listed on this form?

Yes

No

If YES, explain:

Have you ever been pre-medicated for dental treatment?

Yes

No

If YES, why?:

Have you ever taken Fen-Phen?

Yes

No

If YES, when:

Is there any issue or condition that you would like to discuss with the dentist in private?

Yes

No

The practice of dentistry involves treating the whole person. If the dentist determines that there may be a potentially medically-compromised situation, medical consultation may be needed prior to commencement of dental treatment.
I authorize the dentist to contact my physician.

Patient's Signature:

Date:

Physician's Name:

Phone Number:

I certify that I have read and understand this form. To the best of my knowledge, I have answered every question completely and accurately. I will inform my dentist of any change in my health and/or medication. Further, I will not hold my dentist, or any other member of his/her staff, responsible for any errors or omissions that I may have made in the completion of this form.

Signature of Patient (Parent or Guardian):

Date:

Signature of Dentist:

Date:

Medical Updates

I have reviewed my Health History and confirm that it accurately states past and present conditions.

Patient Validation: