Friendlydentalcare.net

Date: _____/_____/_________ Circle One: MR. MRS. MISS
Name: _________________________________________________ Birthdate:_________________
When was your last visit to a dental office? ______________________
Do you have any pain associated with your teeth, gums, mouth, or jaw? YES NO
If YES Please Explain_______________________________________________________________
What is the main reason for your visit?__________________________________________________
Your Physician's Name: _____________________________________________________________
Your Physician's Phone Number: ( ) __________ - _________________
For the following questions, check either YES or NO
YES NO
1. Are you in good health. ____ ____
2. Do you get regular medical check ups. ____ ____
3. Have you had any serious illness or operation. ____ ____
If YES please list illness & date of treatment__________________________
_____________________________________________________________
_____________________________________________________________
4. Any heart problems (congenital disease, damaged/artificial valves,
arteriosclerosis, coronary occlusion, murmurs, heart attack, angina,
pacemaker, etc.)_____________________________________________ ____ ____
5. High Blood Pressure. ____ ____
6. Hepatitis . ____ ____
7. Tuberculosis. ____ ____
8. HIV/AIDS. ____ ____
9. Diabetes. ____ ____
10. Inflammatory rheumatism. ____ ____
11. Prosthetic joints (implants, plates, screws etc.). ____ ____
12. Kidney trouble. ____ ____
13. Cancer. ____ ____
14. Chemotherapy/Radiation Therapy. ____ ____
15. Seizures or fainting spells. ____ ____
16. Stroke. ____ ____
17. Blood disorder/problem. ____ ____
18. Arthritis . ____ ____
19. Herpes. ____ ____
20. Liver disease. ____ ____
21. Sinus trouble . ____ ____
22. Stomach ulcer. ____ ____
23. Asthma. ____ ____
24. Depression/ Anxiety / Nervousness. ____ ____
25. Allergies (local anesthetics, penicillin/antibiotics, codeine, sulfa,
latex, etc.)_________________________________________________ ____ ____
26. Are you taking any medications ( antibiotics, anticoagulants,
blood pressure, steroids, tranquilizers, aspirin, antihistamine, insulin,
nitroglycerin, oral contraceptives, hormonal therapy, etc.)_____________ ____ ____
__________________________________________________________
__________________________________________________________
27. Recreational drugs. ____ ____
28. Pregnant or Nursing. ____ ____
29. Any problems/conditions not listed____________________________ ____ ____
___________________________________________________________
I have read the foregoing & have filled out this health questionnaire completely and truthfully.
SIGNATURE of PATIENT or GUARDIAN ______________________________ DATE____________
SIGNATURE of DENTIST ___________________________________ DATE__________________

Source: http://friendlydentalcare.net/Resources/health_history.pdf