Patient Name ______________________________________________Date_________________
HEALTH HISTORY QUESTIONNAIRE
Honest answers to the questions stated below are important to the provision of dental care. Questions
should be answered to the best of your ability; if uncertain about the question or how it relates to your
health, please discuss it with Dr. Verdinelli or a member of the staff. You can be assured that the
information you provide will not be released without your express permission.
MEDICAL HISTORY
Circle if you have, or have had, any of the following:
Artificial Bones/Joints
Panic Attacks
ADD/ADHD
Hearing/Vision Loss
Handicaps/Disabilities
Addiction to Drugs/Alcohol
AIDS/ARC/HIV
Hepatitis/Liver Problems
Tuberculosis
Women: Nursing
Pregnant/Anticipating Pregnancy
Heart Attack/Stroke
Heart Catheters/Stents
Angina/Chest Pain
Pacemaker
High or Low Blood Pressure
Cancer
Chemotherapy/Radiation
Bleeding Problems/Anemia
Thyroid Disease
Osteoporosis
Diabetes
Hypoglycemia
Seizures/Epilepsy
Asthma
Emphysema
Allergies/Sinus Problems
Ulcers
Stomach/Intestinal Problems
Kidney Problems/Dialysis
Shingles
DENTAL HISTORY
Circle if you have, or have had, any of the following:
Smoking/Tobacco Habit
Jaw Problems (TMJ/TMD)
Non-Fluoridated/Well Water
Reaction to Dental Anesthetic
Dry Mouth
Skin Reaction to Jewelry
Allergy: Amoxicillin/Penicillin
Allergy: Sulfa
Allergy: Tetracycline
Allergy: Latex
Do you have any health problems or allergies not covered in this form? Please describe.
______________________________________________________________________________
______________________________________________________________________________
Please list all of your medications. Include all prescriptions and over the counter medications
(herbal medicines, pain relievers, vitamins). Note by each medication why you take it.
______________________________________________________________________________
______________________________________________________________________________
I have answered all questions truthfully and to the best of my recollection. If there should be a change in
my health, I am to inform Dr. Verdinelli or Dr. Sheres at the earliest convenience.
______________________________________________________________________________
Patient or Guardian Signature
Date