Health History Form

Please note that it is important to fill in all the fields before submitting. Thank you.
Patient Name :
Last Name*
Middle Name First Name*
SSN:*
Home Phone:* ()--
E-mail:*
Physician's Name:*
Phone No:* ()--
Hospital/HMO: ()--
In Case Of Emergancy: Contact Details
His / Her name:*
Phone No:* ()--
Dental History
Why have you come to the dentist today?
Are you currently in pain? Yes No
Do you require antibiotics before dental treatment? Yes No
Your current dental health is :
Good Fair Poor
Have you ever had a serious/difficult problem associated with any previous dental work? Yes No
Do you floss daily? Yes No
Brush daily? Yes No
Type of bristles on your toothbrush?
Hard Medium Soft
Have you ever had gum treatment? Yes No
Do your gums ever bleed? Yes No
Ever Itch? Yes No
Have you ever had periodontal disease? Yes No
Do you now or have you ever experienced pain/discomfort in your jaw joint (TMJ/TMD)? Yes No
Are your teeth sensitive to: Heat Cold
Anything else? 
Do you have any loose teeth? Yes No
Do you still have wisdom teeth? Yes No
Would you like fresher breath? Yes No
Whiter teeth? Yes No
Are you happy with the way your smile looks? Yes No
If not, what would you change? 
Medical History
PLEASE ANSWER ALL QUESTIONS
1. Has there been any change in your health in the past two years? Yes No
2. Date of last medical examination?
3. Are you under any physician's care now? Yes No
4. Have you ever been hospitalized or had any serious illness? Yes No
5. Are you taking any medications or drugs including over the counter medications or oral contraceptives? Yes No
6. Do you take anticoagulants or blood thinners? Yes No
7. Are you using any recreational drugs or tobacco? Yes No
8. Are you pregnant? Months Yes No
9. Are you nursing at present? Yes No
DO YOU HAVE NOW OR HAVE YOU HAD ANY OF THE FOLLOWING:
10. Heart disease, pacemaker, irregular heartbeat or endocarditis Yes No
11. Shortness of breath with limited activity or when lying down Yes No
12. Chest pain or angina or heart attack Yes No
13. Rheumatic fever or rheumatic heart disease Yes No
14. Heart murmur, mitral valve prolapse, or heart defect from birth Yes No
15. Stroke, numbness, or tingling sensations Yes No
16. High or low blood pressure Yes No
17. Fainting spells, convulsions or epilepsy Yes No
18. Nervous break down, emotional problems, anxiety or depressive disorder Yes No
19. Lung disease:T.B., asthma, emphysema Yes No
20. Liver disease: Hepatitis, cirrhosis... Yes No
22. Prolonged bleeding following injuries or surgery, transfusions Yes No
23. Thyroid , Diabetes Yes No
24. Any limitation of activities or Diet Yes No
25. Venereal disease (syphilis, gonorrhea, herpes, warts, other) Yes No
26. Blood disorder (anemia, leukemia or other) Yes No
27. Cancer or cancer treatment (Radiation, Chemotherapy, Surgery) Yes No
28. Thrombophlebitis Yes No
29. Kidney disease, dialysis or transplant Yes No
30. AIDS or Immunosuppressive disorder Yes No
31. Ulcers, stomach or intestinal disease Yes No
32. An unusual reaction to any dental treatment? Yes No
Explain: 
33. Arthritis, Rheumatism, painful joints, osteoporosis Yes No
34. Artificial implants, hip or other Yes No
35. Any visual disorder (glaucoma or other) Yes No
36. Any hearing impairment Yes No
DO YOU HAVE ANY ALLERGY TO:
37. Novacaine, xylocaine, any anesthetics Yes No
38. Penicillin or other antibiotics Yes No
39. Aspirin, codeine, valium, barbiturates or other pain medications Yes No
40. Latex, other allergies, hayfever, hives Yes No
41. Anything that has not been asked?? Yes No
Vital Signs- Blood Pressure: Pulse:


*Signature
Date
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Rating : 5 Dentists Brentwood - 5 Star Rating Review
"The best dentist and office staff in the world!! I drive 4 hours from Northern Nevada to Brentwood for my dental needs. They are always so gentle and very interested in you. No pain ever and I had several crowns, root canals and deep cleanings done and not once did I experience pain and even afterward no soreness or pain. It may sound funny to say, But I love my dentist and his office staff!!"
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