Health History
DIRECTIONS TO THE PATIENT: The following information about your health history is very important for us to provide you with the
best possible dental care in a safe way. Incorrect information may be dangerous to your health. ALL questions must be answered
completely and accurately. If you don’t understand a question, or are unsure of the answer, or want to discuss it with the dentist,
highlite a number or letter. This Health History Questionnaire will become a part of the patient’s dental record and will be considered
confidential information.
PATIENT NAME: TODAY’S DATE:
BIRTH DATE:
Primary Care Physician:
Physician Office Telephone:
Physician Address:
1. Are you in good health? Yes No Unsure
2. Has there been any change in your health in the last year? Yes No Unsure
If yes, explain:
3. Have you ever been hospitalized, had a major operation or Yes No Unsure
serious illness?
If yes, explain:
4. Date of your last visit to the doctor: Reason for last visit:
5. Are you currently receiving treatment or regular medical care by Yes No Unsure
your doctor?
If yes, for what condition(s)?
6. Are you taking any of the following medications:
a. Antibiotics or sulfa drugs Yes No Unsure
b. Anticoagulant (blood thinners) Yes No Unsure
c. Medication for high blood pressure Yes No Unsure
d. Cortisone (steroids) Yes No Unsure
e. Tranquilizers Yes No Unsure
f. Antihistamines Yes No Unsure
g. Aspirin Yes No Unsure
h. Insulin, tolbutamide (Orinase) or other drugs for diabetes Yes No Unsure
i. Digitalis or drugs for heart trouble Yes No Unsure
j. Nitroglycerin Yes No Unsure
k. Birth control pills or other hormones Yes No Unsure
I. Pain medications such as Advil, Nuprin, Motrin or Naprosyn Yes No Unsure
m. Synthroid or other thyroid medication Yes No Unsure
n. AZT or other drugs for HIV Yes No Unsure
o. Others, please list:
7. Have you ever taken fen-phen (fenfluramine/phentermine Yes No Unsure
combination)?
If so, have you had a cardiac (heart) exam by your physician? If yes, specify what substance/medications, and what reactions:
HAVE YOU EVER BEEN TREATED BY A DOCTOR FOR:(Circle
your response and underline any conditions that apply):
9. Damaged heart valves, artificial heart valves, heart Yes No Unsure
murmur, rheumatic fever, rheumatic heart disease
10. Congenital heart problems Yes No Unsure
11. Heart trouble, heart attack, high blood pressure, stroke? Yes No Unsure
a. Do you have pain in your chest upon exertion? Yes No Unsure
b. Are you ever short of breath after mild exercise? Yes No Unsure
c. Do your ankles swell? Yes No Unsure
14. Breathing problems, emphysema, tuberculosis or Yes No Unsure
other lung problems?
15. Asthma, hay fever or hives? Yes No Unsure
16. Stomach or intestinal ulcers? Yes No Unsure
17. Cancer, x-ray treatments, or chemotherapy? Yes No Unsure
18.Thyroid trouble? Yes No Unsure
19.Diabetes or blood sugar problems? Yes No Unsure
20. Hepatitis, jaundice, or liver disease? Yes No Unsure
21. Kidney infections, frequent urination, or renal (kidney) dialysis? Yes No Unsure
22. Stroke, seizures, fainting spells, numbness or other neurological Yes No Unsure
problems?
24. AIDS, AIDS-related condition or HIV positive? Yes No Unsure
25. Tumors or growths? Yes No Unsure
26. Arthritis or rheumatism? Yes No Unsure
27. Phobias, severe anxieties, depression, psychoses, unusual Yes No Unsure
fears, or other mental problems?
28. Psoriasis, seborrhea, or other skin diseases? Yes No Unsure
29. For women, are you pregnant or do you think you may be Yes No Unsure
pregnant?
30. For women, are you nursing? Yes No Unsure
OTHER MEDICAL CONCERNS:
31. Do you have complaints regarding your eyes, ears or nose? Yes No Unsure
If yes, explain:
32. Do you wear contact lenses? Yes No Unsure
33. Have you received blood or blood by-products? Yes No Unsure
If so, please list: type: amount: date:
SIGNATURE OF PATIENT: I understand the need for these questions to be answered truthfully. To the best of my
knowledge, the answers I have given are accurate. I also understand it is very important to report any changes in
my medical or dental status to the dentist at the earliest possible time, and I agree to do so. I give my permission to
the dentist to obtain from my physician any additional information regarding my medical history needed to provide
me the best dental treatment possible.
PERSON COMPLETING FORM:
Signature of Patient:_________________________________________________________
(If other than patient, indicate relationship):_______________________________________
Date:_______________________________________________
