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Health History Form

Please fill in the following form and submit it to electronically.
You may also fill out the form, print it, and bring it with you to your next appointment.

Patient Information
Last Name First Name Middle
Patient Address Zip Code

Phone No Date of Birth SSN
Parent/Legal Guardian
Address Zip Code
Daytime Phone Other Phone
Dental Insurance
Dental Insurance Name Group No
Insurance Company Address Zip Code
Name of Insured Date of Birth SSN
Address of Insured Zip Code
Employer's Name
Emergency Contact
Name Phone

Patient Health History
  Y   N  
Is the patient in good health?
Is the patient currently under the care of a physician?
Have there been any changes in general health within the past year?
Have there been alergies or reactions to any medication or drugs?
Has there ever been any excessive bleeding requiring treatment?
Has the patient ever required a blood transfusion?
Has the patient ever had the following:
Y N   N   Y N  
Heart Failure Asthma Tuberculosis
Heart Disease Anemia Hepatitis A or B
Heart Surgery Diabetes AIDS or HIV
Heart Murmer Lukemia Hemophilia
Angina Pectoris Allergies Epilepsy / Seizures
Rheumatic Fever Artificial Joint Venereal Disease
Artificial Heart Valve Kidney Trouble Genital Herpes
High Blood Pressure Thyroid Disease Cold Sores
Breathing Problems Liver Disease Cancer
    Others not listed
    Medications Taken
  Dental   Medical
Date of last
Dental Exam:
Date of last
Medical Exam:
Dentist's Name: Physician's Name:
Phone Number: Phone Number:
Office Address: Office Address:
City and Zip: City and Zip:
To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my child's health. It is my responsibility to inform the dental office of any changes in medical status.
Date Signature of Parent or Guardian How were you referred to our office?

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