Dental Health History Form
Patient Name _________________________________________ Phone Number ____________________________
Address __________________________________________________________________________________________
Date of Birth ___ ___ /___ ___/___ ___ ___ ___
Social Security Number ___ ___ ___-___ ___- ___ ___ ___ ___
Health History
1. Circle any of the following that you have or have had in the past:
Blood Pressure: high or low
Rheumatic Fever
Hepatitis
Heart Disease
Asthma/COPD
Tuberculosis
Heart Valve
Stroke
Seizures
Stomach Problems
(ulcers, reflux, etc.)
Kidney Disease
Immunocompromised Disease
Joint Replacement
Thyroid Problems
Seasonal Allergies
Diabetes
Back Problems
Sinus Problems
Cancer/Radiation
Hemophilia
Pancreatitis
Bleeding Problems
Headaches
Pacemaker
Other:
2. Have you ever had an allergic reaction to any of the following: (circle) Medication
Food Latex
Please explain: ______________________________________________________________________________________________
3. Please list all medications (prescribed and/or over-the-counter) that you are currently taking:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
4. Please list any medications you are currently taking or have taken in the past for osteoporosis (i.e. Boniva,
Actonel, Fosamax)_________________________________________________________________________
5. Have you ever had a serious illness, operation, or been hospitalized? If so, please explain:
________________________________________________________________________________________
6. Women only: a. Are you pregnant or do you think you may be pregnant?
b. Are you currently taking oral birth control: Yes No
Yes
No
7. Please list your primary care doctor/provider and contact number:
Medical Provider:_________________________________ Phone Number:_________________________

 
Dental Health History Form
Social History
8. Do you use tobacco? Yes
No
If yes: How much and what type: ______________________________
How long have you used it: ______________________________
9. Do you now or have you ever use controlled substances (drugs) recreationally?
Yes
No
10. Do you now or have you ever received treatment at a pain clinic?
Yes
No
Dental History
11. What is the reason for your dental visit today?
Broken tooth/
Broken filling
Exam
Pain/Swelling
Cleaning
Treatment
12. How long has this been a problem or concern? _________________________________________________
13. When was your last dental visit? ____________________________________________________________
Reason for that visit: ______________________________________________________________
14. Have you ever been shown how to brush and/or floss?
15. How many snacks do you eat per day (candy, pop, etc…)?
Yes
No
None
1 – 2 Per Day
3 – 4 Per Day
5 – 6 Per Day
More than 4 per
day
The above information is accurate and complete, to the best of my knowledge, and is only for use in my
treatment, billing and processing of insurance benefits for which I am entitled. I will not hold my dentist or any
member of his/her staff responsible for any errors or omissions that I may have made in the completion of this
form.
Patient/Guardian Signature__________________________________________ Date____________________
Dentist/Hygienist Signature__________________________________________ Date____________________
For Office Use Only:
Guardianship verification received: Date _________________________ Employee Initials______________