Health History Form

E-mail: Today’s Date:

As required by law, our office adheres to written policies and procedures to protect the privacy of information about you that we create, receive or maintain. Your
answers are for our records only and will be kept confidential subject to applicable laws. Please note that you will be asked some questions about your responses to
this questionnaire and there may be additional questions concerning your health. This information is vital to allow us to provide appropriate care for you. This office
does not use this information to discriminate.
Name: Home Phone: Include area code Business/Cell Phone: Include area code

Last First Middle ( ) ( )

Address: City: State: Zip:

Mailing address
Occupation: Height: Weight: Date of birth: Sex: M F

SS# or Patient ID: Emergency Contact: Relationship: Home Phone: Cell Phone:
( ) ( )
Include area codes

If you are completing this form for another person, what is your relationship to that person?
Your Name Relationship
Do you have any of the following diseases or problems: (Check DK if you Don't Know the answer to the question) Yes No DK
Active Tuberculosis ................................................................................................................................................................................................... n n n
Persistent cough greater than a 3 week duration ..................................................................................................................................................... n n n
Cough that produces blood...................................................................................................................................................................................... n n n
Been exposed to anyone with tuberculosis ............................................................................................................................................................... n n n
If you answer yes to any of the 4 items above, please stop and return this form to the receptionist.

Dental Information For the following questions, please mark (X) your responses to the following questions.
Yes No DK Yes No DK
Do your gums bleed when you brush or floss? ........................... n n n Do you have earaches or neck pains? ........................................ n n n
Are your teeth sensitive to cold, hot, sweets or pressure? ........... n n n Do you have any clicking, popping or discomfort in the jaw? .... n n n
Does food or floss catch between your teeth? ............................ n n n Do you brux or grind your teeth? .............................................. n n n
Is your mouth dry?...................................................................... n n n Do you have sores or ulcers in your mouth? .............................. n n n
Have you had any periodontal (gum) treatments?....................... n n n Do you wear dentures or partials?............................................. n n n
Have you ever had orthodontic (braces) treatment? .................... n n n Do you participate in active recreational activities? .................... n n n
Have you had any problems associated with previous dental Have you ever had a serious injury to your head or mouth? ...... n n n
treatment?................................................................................... n n n Date of your last dental exam:
Is your home water supply fluoridated? ...................................... n n n What was done at that time?
Do you drink bottled or filtered water?....................................... n n n
If yes, how often? Circle one: DAILY / WEEKLY / OCCASIONALLY Date of last dental x-rays:
Are you currently experiencing dental pain or discomfort?.......... n n n
What is the reason for your dental visit today?

How do you feel about your smile?

Medical Information Please mark (X) your response to indicate if you have or have not had any of the following diseases or problems.
Yes No DK Yes No DK
Are you now under the care of a physician? ............................... n n n Have you had a serious illness, operation or been
Physician Name: Phone: Include area code hospitalized in the past 5 years? ................................................ n n n
( ) If yes, what was the illness or problem?
Address/City/State/Zip:
Are you taking or have you recently taken any prescription
Are you in good health? ............................................................. n n n or over the counter medicine(s)? .............................................. n n n
Has there been any change in your general health within If so, please list all, including vitamins, natural or herbal preparations
the past year? .............................................................................. n n n and/or diet supplements:
If yes, what condition is being treated? __________________________________________________________________
__________________________________________________________________
__________________________________________________________________
Date of last physical exam:
__________________________________________________________________

© American Dental Association, 2006

Form S500
Medical Information Please mark (X) your response to indicate if you have or have not had any of the following diseases or problems.

(Check DK if you Don't Know the answer to the question) Yes No DK Yes No DK
Do you wear contact lenses? ......................................................... n n n Do you use controlled substances (drugs)? ................................... n n n
Are you taking, or have you taken, any diet drugs such as Do you use tobacco (smoking, snuff, chew, bidis)? ...................... n n n
Pondimin (fenflluramine), Redux (dexphenfluramine) or If so, how interested are you in stopping?
phen-fen (fenflluramine-phentermine combination)? ..................... n n n (Circle one) VERY / SOMEWHAT / NOT INTERESTED
Are you taking or scheduled to begin taking either of the Do you drink alcoholic beverages? ............................................... n n n
medications, alendronate (Fosamax®) or risedronate (Actonel®) If yes, how much alcohol did you drink in the last 24 hours? _______________
for osteoporosis or Paget’s disease?............................................... n n n If yes, how much do you typically drink In a week? _______________________
Since 2001, were you treated or are you presently scheduled WOMEN ONLY Are you:
to begin treatment with the intravenous bisphosphonates Pregnant?..................................................................................... nn
Pregnant?...................................................................................... nn nn
(Aredia® or Zometa®) for bone pain, hypercalcemia or skeletal ___________
Number of weeks: _____________
complications resulting from Paget’s disease, multiple myeloma Taking birth control pills or hormonal replacement? ..................... ...................... nn nn nn
or metastatic cancer? .................................................................... n n n Nursing? ...................................................................................... nn
Nursing?........................................................................................ nn nn
Date Treatment began: _______________________________________________
Joint Replacement. Have you had an orthopedic total joint (hip, knee, elbow, finger) replacement? ........................................................................ n n n
Date: _________________________ If yes, have you had any complications?
Allergies - Are you allergic to or have you had a reaction to: Yes No DK Yes No DK
To all yes responses, specify type of reaction. Metals __________________________________________________ n n n
Local anesthetics__________________________________________ n n n Latex (rubber) ___________________________________________ n n n
Aspirin __________________________________________________ n n n Iodine __________________________________________________ n n n
Penicillin or other antibiotics ________________________________ n n n Hay fever/seasonal________________________________________ n n n
Barbiturates, sedatives, or sleeping pills_______________________ n n n Animals_________________________________________________ n n n
Sulfa drugs ______________________________________________ n n n Food ___________________________________________________ n n n
Codeine or other narcotics _________________________________ n n n Other___________________________________________________ n n n
Please mark (X) your response to indicate if you have or have not had any of the following diseases or problems.
Yes No DK Yes No DK Yes No DK Yes No DK
Heart murmur .................. n n n Anemia............................. n n n Chronic pain....................... n n n Sleep disorder..................... n n n
Mitral valve prolapse......... n n n Blood transfusion .............. n n n Diabetes Type I or II....... n n n Mental health disorders ...... n n n
Artificial heart valves ........ n n n If yes, date:_______________________ Eating disorder ................... n n n Specify:___________________________
Rheumatic fever .............. n n n Hemophilia ....................... n n n Malnutrition ....................... n n n Recurrent Infections............ n n n
AIDS or HIV infection ......... n n n Gastrointestinal disease ...... n n n Type of infection:___________________
Cardiovascular disease. ...... n n n Arthritis ............................ n n n G.E. Reflux/persistent Kidney problems................. n n n
Angina ............................. n n n Autoimmune disease ......... n n n heartburn ........................... n n n Night sweats ...................... n n n
Arteriosclerosis .................. n n n Rheumatoid arthritis .......... n n n Ulcers ................................. n n n Osteoporosis....................... n n n
Congestive heart failure ..... n n n Systemic lupus Thyroid problems................ n n n Persistent swollen glands
Coronary artery disease ...... n n n erythematosus................ n n n Stroke................................. n n n in neck ............................ n n n
Damaged heart valves ........ n n n Asthma............................. n n n Glaucoma........................... n n n Severe headaches/
Heart attack ...................... n n n Bronchitis .......................... n n n Hepatitis, jaundice or migraines ........................ n n n
Low blood pressure ........... n n n Emphysema ...................... n n n liver disease..................... n n n Severe or rapid weight loss.. n n n
High blood pressure ........... n n n Sinus trouble ..................... n n n Epilepsy .............................. n n n Sexually transmitted disease . n n n
Congenital heart defects .... n n n Tuberculosis ...................... n n n Fainting spells or seizures ... n n n Excessive urination.............. n n n
Pacemaker ........................ n n n Cancer/Chemotherapy/ Neurological disorders ...... n n n
Rheumatic heart disease..... n n n Radiation Treatment ........ n n n If yes, Specify:_____________________
Abnormal bleeding ............ n n n Chest pain upon exertion ... n n n
Has a physician or previous dentist recommended that you take antibiotics prior to your dental treatment? ............................................................... n n n

Name of physician or dentist making recommendation: Phone:

Do you have any disease, condition, or problem not listed above that you think I should know about? ...................................................................... n n n
Please explain:

NOTE: Both Doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment.
I certify that I have read and understand the above and that the information given on this form is accurate. I understand the importance of a truthful health
history and that my dentist and his/her staff will rely on this information for treating me. I acknowledge that my questions, if any, about inquiries set forth
above have been answered to my satisfaction. I will not hold my dentist, or any other member of his/her staff, responsible for any action they take or do not
take because of errors or omissions that I may have made in the completion of this form.
Signature of Patient/Legal Guardian: Date:

FOR COMPLETION BY DENTIST

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