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Name ________________________________________________ Single ______ Married ______ Divorced ______ Email ___________________________ Social Security Number ____________________ Birthdate ____________ Home Phone ______________________ Cell Phone ______________________ Residence Address ____________________________________________________ City _____________________ State __________ Zip _____________ Employed By _________________________________________________________ City _____________________ State __________ Zip _____________ Present Position ____________________________________ How Long Held ________________ Business Phone ________________________________ Spouse Name _________________________________________________________________________________________________________________ Spouse’s Social Security # ____________________ Spouse Birthday ________________ Business Phone _______________________________________ Spouse Employed By ___________________________________________________ City _____________________ State __________ Zip _____________ Present Position __________________________________________________________________________________ How Long Held ________________ Referred By _____________________________________________ Address ______________________________________________________________ Who will pay for this account? _____________________________________________________________________________________________________ Name of your dental insurance company ____________________________________________________________________________________________ Group # _______________________________________________________ Policy # _______________________________________________________ Name of your spouse’s dental insurance company _____________________________________________________________________________________ Group # _______________________________________________________ Policy # _______________________________________________________ Emergency Contact: Name ________________________________________ Address_______________________________________________________ Cell Phone ____________________________________ Home Phone ___________________________________________________ Dental History
Do you have a specific dental problem? Describe _____________________________________________________________________________ Yes
Do you have dental examinations on a routine basis? Last visit __________________________________________________________________ Yes Do you think you have active decay or gum disease? __________________________________________________________________________ Yes Do you brush and floss on a routine basis? __________________________________________________________________________________ Yes Do your gums ever bleed? Discuss ________________________________________________________________________________________ Yes Does food catch between your teeth? ______________________________________________________________________________________Yes Any loose teeth?_______________________________________________________________________________________________________ Yes Do your want to keep your remaining teeth? _________________________________________________________________________________ Yes Do you ever have clicking, popping or discomfort in the jaw joint? ________________________________________________________________ Yes Do you grind your teeth? ________________________________________________________________________________________________ Yes Have your past experiences in a dental office always been positive? ______________________________________________________________ Yes Do you smoke or chew? _________________________________________________________________________________________________ Yes Any sores or growths in your mouth? Discuss ________________________________________________________________________________ Yes Name of previous dentist (optional): ________________________________________________________________________________________ Yes Date of last full mouth x-rays (16 small films or panoramic): _____________________________________________________________________ Yes Have you or any member of your family been a patient in our office before?_________________________________________________________ Yes If so, who?____________________________________________________________________________________________________________ Answer all questions by circling Yes (Y) or No (N)
All responses are kept confidential
7. ARE YOU USING ANY OF THE FOLLOWING:
B. Anticoagulants (Blood Thinners)? . Y N C. Aspirin or drugs such as Motrin, Aleve, Ibuprofen? . Y N 4. Are you now under a physician’s care for D. High Blood Pressure medications . Y N E. Steroids (Cortisone, Prednisone, etc.)? . Y N 5. Have you ever had any serious illnesses, F. Insulin or Oral Anti-Diabetic drugs? . Y N operations or hospitalizations? If so, describe . Y N G. Digitalis, Inderal, Nitroglycerin or other heart drug? . Y N __________________________________________________ I. Are you taking or have you ever taken
__________________________________________________ Bisphosphonates for osteoporosis, multiple myeloma 6. DO YOU HAVE OR HAVE YOU EVER HAD:
or other cancers (Reclast, Fosamax, Actonel, A. Rheumatic Fever or Rheumatic Heart Disease? . Y N J. Please list any and all medications taken: ______________________________________________ (Heart Attack, Heart Trouble, Heart Murmur, ______________________________________________ 8. ARE YOU ALLERGIC TO OR HAVE YOU HAD AN
High Blood Pressure, Stroke, Palpitations, ADVERSE REACTION TO:
A. Local Anesthesia (Novacain, etc.)? . Y N D. Lung Disease (Asthma, Emphysema, COPD, B. Penicillin or other antibiotics? . Y N Tuberculosis, Shortness of Breath, Chest Pain, F. Bleeding Disorder, Anemia, Bleeding Tendency, H. Other allergies or reactions? Please list . Y N Blood Transfusion? Do you bruise easily? . Y N __________________________________________________ G. Liver Disease (Jaundice, Hepatitis)? . Y N __________________________________________________ 9 . Is there any past history of Alcohol or Chemical Dependency or Emotional Disorder that may affect 10. Have you had any serious problems associated with 11. Do you have any other disease, condition or problem not listed above that you think the doctor should O. Implants placed anywhere in your body (Heart Valve, Pacemaker, Hip, Knee)?. Y N 12. Do you wish to talk to the doctor privately about anything? . Y N P. Radiation (X-ray) treatment for Cancer? . Y N 13. FOR WOMEN ONLY
A. Are you Pregnant, or is there any chance
R. Any disease, drug or transplant operation that has depressed your immune system (HIV)? . Y N I understand the importance of a truthful and complete Health History to assist my doctor in providing the best care possible.
________________________________ ________________________________________________ ___________________________
Date
Signature of Person Completing Health History

Source: http://www.bennettandmaxwellfamilydentistry.com/web_images/205008_adulthealth.pdf

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