Health History
Correct answers to the following questions will allow your dental team to treat you on a more individual basis,
providing the care appropriate for your particular needs.
Name___________________________________ Date of Birth________________ Age________________
Why are you now seeking dental treatment? _____________________________________________________________
Are you currently in pain? _____________________________________________________________________________
Please answer each question. Check YES or NO. If in doubt, leave blank.
1. Your current physical health is
Good
Fair
Poor
2. Are your under the care of a physician?..............................................................YES
If yes, what is the condition being treated? ___________________________
3. Have you ever been hospitalized or had a serious illness?..................................YES
4. (WOMEN) Are you pregnant? If yes, give due date_______________________YES
New MOTHERS are you nursing?.........................................................................YES
5. Do you use tobacco in any form? If yes, how much?...........................................YES
6. Do you consume more than 2 alcoholic drinks per day?.....................................YES
7. Do you need to be premedicated before dental treatment?..............................YES
NO
NO
NO
NO
NO
NO
NO
Please check YES or NO to the following questions. DO NOT LEAVE BLANK!
8. Do you currently have or had a history of the following?
GENERAL
NERVOUS SYSTEM
Swollen Extremities…………………….YES NO
Alcohol/Drug abuse……………………..YES
Tire easily, weakness………………....YES NO
Stroke…………………………………………..YES
Marked weight change……………….YES NO
Headaches……………………………………YES
Night sweats……………………………….YES NO
Convulsions/Epilepsy/Seizures…….YES
Persistent Fever…………………………YES NO
Numbness/Tingling………………………YES
Dizziness/Fainting…………………………YES
SKIN
Psychiatric treatment…………………..YES
Eruptions (rash) Hives………………..YES NO
Other……………………………………………YES
Change in skin color………………….. YES NO
Other…………………………………………YES NO
RESPIRATORY SYSTEM
Tuberculosis (TB)………………………….YES
EYES
Asthma/Hay fever………………………..YES
Visual Change…………………………….YES NO
Persistent Cough………………………….YES
Glaucoma…………………………………..YES NO
Sputum production (Phlegm)………YES
Other…………………………………………YES NO
Cough up blood sputum………………YES
Other…………………………………………..YES
EARS
Loss of hearing…………………………..YES NO
ENDOCRINE
Ringing in ears…………………………..YES
NO
Diabetes……………………………………..YES
Other…………………………………………YES NO
Family history of diabetes…………..YES
Thyroid condition/Goiter……………YES
NOSE
Other………………………………………….YES
Frequent nose bleeds………………YES
NO
Sinus problems………………………..YES
NO
THROAT
Other……………………………………….YES
NO
Soreness/Hoarseness………………..YES
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
Health History
HEART/BLOOD VESSELS
Stroke……………………………………………..YES
Rheumatic fever/Scarlet Fever………YES
Heart Murmur………………………………..YES
Chest pain/discomfort…………………..YES
Heart attack/trouble………………………YES
Shortness of breath……………………….YES
Swelling of ankles…………………………..YES
High blood pressure…………………….…YES
Low blood pressure……………………….YES
Congenital heart disease……………….YES
Mitral Valve prolapsed……………….….YES
Artificial heart Valve……………………...YES
Pacemaker……………………………….. .…YES
Heart surgery…………………………….….YES
Other…………………………………………….YES
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
BLOOD
Hemophilia/Abnormal Bleeding……YES
Bruise easily………………………………….YES
Anemia…………………………………………YES
Blood Transfusion………………………..YES
Sickle Cell Disease………………………..YES
Other………………………………………….YES
NO
NO
NO
NO
NO
NO
BONE/MUSCLES
Arthritis/Rheumatism………………….YES
Artificial joints/limbs…………………..YES
Other…………………………………………..YES
NO
NO
NO
DIGESTIVE SYSTEM
Hepatitis………………………………….........YES
Jaundice…………………………………………..YES
Ulcers……………………………………………….YES
Change in appetite……………………………YES
Black, bloody or pale stools………………YES
URINARY
Kidney disease………………………………….YES
Increase in frequency of
urination during the night………………..YES
Burning on urination………………………..YES
Urethral discharge……………………………YES
Bloody urine…………………………………….YES
Venereal disease……………………………..YES
Difficulty breathing while lying down.YES
OTHER
Radiation Therapy…………………………….YES
Chemotherapy…………………………………YES
Tumors or growths……………………………YES
Cancer/Type…………………………………….YES
HIV+…………………………………………………YES
AIDS…………………………………………………YES
Have you ever been tested for HIV? YES
Mental Retardation…………………………YES
Cold Sores………………………………………..YES
Herpes……………………………………………..YES
Organ Transplant……………………………..YES
9. Have you ever had Nitrous Oxide (Laughing Gas) administered during dental treatment?..................YES
If yes, was it a pleasant experience?
YES
NO
10. Are you now taking any of the following?
Antibiotics/Sulfa drugs………………..YES NO
Nitroglycerin…….YES NO
Thyroid medicine..……YES
Blood pressure medication………….YES NO
Blood Thinners…YES NO
Tranquilizers…………….YES
Cortisone/Steroid medication.......YES NO
Cold remedies…YES NO
Aspirin……………………..YES
Digitalis/other heart medication….YES NO
Antihistamines/Allergy drugs.……..YES NO
Insulin/other Diabetes drugs……...YES NO
Recreational drugs/Illegal drugs…..YES NO
Other…………………………………………..YES NO
Osteoporosis Medication …………….YES NO
If yes to any of the above, list name of medication and dosage below:
1.
2.
3.
4.
5.
__________________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
Health History
11. Are you ALLERGIC to or have you ever experienced any reaction to the following?
Local anesthetics (e.g. Novocaine)…..YES NO
Erythromycin…………YES NO Aspirin…………..….YES NO
Barbiturates/sedatives/sleeping pills..YES NO Tetracycline…………..YES NO Sulfa Drugs……....YES NO
Any Metallic allergy…………………………..YES NO
Penicillin……………….YES NO Codeine……………YES
NO
Other………………………………………………..YES NO
12. Is there any disease, condition, or problem not listed above that you think we should know about, or is there any
activity your physician says you CANNOT do? If so explain____________________________________________
13. Are you under any unusual stress at home or work? _________________________________________________
14. Physician’s name_____________________________________
Date of last visit______________________
15. Have you ever had any serious trouble (bad experiences) associated with previous dental treatment?_________
___________________________________________________________________________________________
16. Does dental treatment make you nervous?
Slightly
Moderately
Extremely
17. Date of last dental visit _________________________
18. Have you ever been treated for periodontal disease (gum disease, pyorrhea, trench mouth)?_______________
19. Do you have or have you ever had any of the following?
MOUTH
Teeth
Bleeding, sore gum…………………………YES NO
Loose teeth…………….YES
NO
Unpleasant taste/bad breathe……….YES
NO
Sensitive to hot………YES
NO
Burning tongue/lips…………………………YES NO
Sensitive to cold……..YES
NO
Frequent blisters, lips/mouth………….YES NO
Sensitive to sweets…YES
NO
Swelling/lumps in mouth…………………YES NO
Sensitive to biting……YES
NO
Orthodontic Treatment (braces)………..YES NO
Food impaction……….YES
NO
Biting cheeks/lips…………………………….YES NO
Clenching/grinding….YES
NO
Clicking/popping jaw………………………..YES NO
Shifting of teeth………YES
NO
Difficulty opening or closing……………..YES NO
Change in Bite………….YES
NO
Would you like to prevent dentures..YES NO
Do you like the appearance of your teeth…………..YES
NO
Are your teeth all in alignment (Straight)…………….YES NO
ORAL HYGIENE
Do you have spaces that you don’t like………………..YES NO
Do you use the following:
Do you like the color of your teeth……………………..YES
NO
Tooth brush………………….YES NO
Do you like the shape of your teeth…………………….YES
NO
Dental Floss………………….YES NO
Do you like the way your teeth come together……YES
NO
Fluoride rinse……………….YES NO
Are there old fillings or dental work that you do
Water irrigator……………..YES NO
not like looking at……………………….……………………YES NO
Other……………………………………..
Do you gag easily…………………………………………………..YES NO
Are your teeth:
Chipped ____Protruding
Hidden
How would you rate your smile on a scale of 1-10 (10 being the highest)?________________________________
What would you like to change the most in the appearance of your teeth?_______________________________
How often do you brush?___________________
Type of brush____________________________
Brush is:
Soft
Medium
Hard
To the best of my knowledge, all of the proceeding answers are true and correct.
If I have any change in my health or change my medication, I will inform the dentist at the next appointment.
Signature of patient
Parent, or Guardian____________________________________
Date__________________________