Health History Form Patient Information (Confidential)Date MM slash DD slash YYYY Name First Last Birthdate MM slash DD slash YYYY SpouseAgeSexSS#/ SINEmail(Required) Address(Required) Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP / Postal Code(Required)ZIP / Postal CodePhone(Required)Check Appropriate Box Minor Single Married Divorced Widowed Separated EmployerWork PhoneWhom may we thank for referring you?Person to contact in case of emergencyEmergency Contact Phone(Required)Insurance InformationDo you have Insurance? Yes No Name of InsuranceMember ID NumberName of InsuredRelationship to PatientBirthdate MM slash DD slash YYYY SS#SINName of EmployerWork PhoneDo you have any additional insurance? Yes No Name of InsuredRelationship to PatientBirthdate MM slash DD slash YYYY SS#/SINName of EmployerWork PhonePatient Dental HistoryName of Previous Dentist & LocationDate of Last Exam MM slash DD slash YYYY Do your gums bleed while brushing or flossing? Yes No Do you have frequent headaches? Yes No Do you feel pain with any of your teeth? Yes No Do you have any sores or lumps in or near your mouth? Yes No Do you bite your lip or cheeks frequently? Yes No Have you ever had a difficult extractions in the past? Yes No Have you had any head, neck , or jaw injuries? Yes No Have you ever had any prolonged bleeding following extractions? Yes No Have you ever had any orthodontic treatment? Yes No Have you received oral hygiene instructions regarding your teeth? Yes No Do you wear dentures or partials? Yes No If yes, date of placement MM slash DD slash YYYY Have you ever experienced the following problems in your jaw? Pain (joint, ear, side of face) Yes No Difficulty in chewing? Yes No Clicking Yes No Clench or grind in your teeth Yes No Difficulty in opening or closing? Yes No Are your teeth sensitive? Please explain:Any other concerns?Patent Medical HistoryPhysicianOffice PhoneDate of Last Exam MM slash DD slash YYYY Are you under medical treatment now? Yes No Have you ever had any surgical operation or serious illness within the last 5 years? Yes No If yes, please explainAre you taking any medication(s) including non-prescription(s)? Yes No Please list the medications here.Have you ever taken Fosamax, Boniva, Actonel, Prolea or any medication for bone heath? Yes No Cancer medication containing bisphosphonates? Yes No Do you use tobacco? Yes No If yes, Smoke Chew Do you use controlled substances? Yes No Do you have a persistent cough or throat clearing not associated with a known illness? Yes No Has the cough lasted more than 3 weeks? Yes No Are you allergic to to have reactions to: Local Anesthetics (e.g. Novocain)? Yes No Penicillin or any other Antibiotics Yes No Sulfa Drugs Yes No Barbiturates Yes No Sedatives Yes No Iodine Yes No Aspirin Yes No Any metals (e.g. nickle, mercury, ect.) Yes No Latex Rubber Yes No Other (please list)Are you taking blood thinners? Yes No Women Only Are you pregnant/think you might be pregnant? Yes No If yes, what trimester?Are you nursing? Yes No Are you taking oral contraceptions? Yes No Do you have or have you had any of the following? High Blood Pressure? Yes No Heart Attack Yes No Rheumatic Fever Yes No Swollen Ankles Yes No Fainting/Dizzy Spells Yes No Impaired Memory Yes No Low Blood Pressure Yes No Lukemia Yes No Kidney Disease Yes No Diabetes Yes No TypeKidney Disease Yes No AIDS or HIV Infection Yes No Thyroid Problems Yes No Heart Disease Yes No Cardiac Pacemaker Yes No Heart Murmur Yes No Angina/Pectoris Yes No Frequently Tired Yes No Anemia Yes No Cancer Yes No Type/KindRadiation Therapy Yes No Arthritis Yes No Rheumatism Yes No Joint Replacement or Implant Yes No What Kind Hip Knee Shoulder Emphysema Yes No Easily Winded Yes No Sexually Transmitted Disease Yes No Hepatitis/Jaundice Yes No TypeStomach Troubles/Ulcers/GERD Yes No Chest Pains Yes No Asthma Yes No Stroke Yes No Hey Fever/Allergies Yes No Tuberculosis Yes No Glaucoma Yes No Recent Weight Loss Yes No Liver Disease Yes No Respiratory Problems Yes No Mitral Valve Prolapse Yes No Other Authorization and Release I certify that I have read and understand the above information to the best of my knowledge. The above questions have been accurately answered. I understand that providing incorrect information can be dangerous to my health. I authorize the dentist to release any information including the diagnosis and the records of any treatment or examination rendered to me or my child during the period of such Dental care to third party payers and/or health practitioners. I authorize and request my insurance company to pay directly to the dentist or dental group insurance benefits otherwise payable to me. I understand that my dental Insurance carrier may pay less than the actual bill for service. I agree to be responsible for payment of all services rendered on my behalf or my dependents. Past due balances are subject to a 1.5% monthly late charge.Signature of patient (or parent/guardian if minor)Date MM slash DD slash YYYY Please confirm that you have reviewed the form and filled everything out correctly.(Required) Yes, I have. 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