Patient Health History

(Your answers are for our records only and will be kept confidential)

Yes No
Has there been any changes in your general health within the past year?
Name of your Physician:
Physician's phone number:
When was your last physical examination:
Have you had any serious illness, operation or been hospitalized in the past 5 years?
Are you taking any medicines, prescription or non-prescription? If so please list:

Do you have, or have you had in the past, any of the following:
Damaged heart valves or artiffcial heart valves, including heart murmur or rheumatic heart disease
Cardiovascular disease: (heart trouble, heart attack, angina, coronary insufficiency, coronary occlusion, high blood pressure, stroke or arteriosclerosis
Chest pains
Shortness of breath after mild exercise or when lying down
Heart defect or heart murmur
Swelling of the ankles
Sinus trouble
Asthma or hay fever
Fainting spells or seizures
Persistant diarrhea or recent weight loss
Diabetes or a family history of diabetes
Hepatitis, jaundice or liver disease
Aids or HIV infection
Thyroid problems
Respiratory problems, emphysema, bronchitis, etc.
Arthritis or painful swollen joints
Stomach ulcer or hyper-acidity
Kidney trouble
Persistent cough or a cough that produces blood
Persistent swollen glands in neck
Low blood pressure or high blood pressure
Sexually transmitted disease such as gonorrhea, syphilis or herpes
Epilepsy or other neurological disease
Emotional problems
Abnormal or excessive bleeding
Have you ever required a blood transfusion
Treatment for tumor growth
Artificial joint replacement
Mitral valve prolapse
Are you allergic or have you had a reaction to any of the following?
Penicillin or other antibiotics
Sulfa drugs
Barbiturates, sedatives, or sleeping pills
Codeine or other narcotics
Other - Please List:
Do you smoke or use tobacco in any form?
Do you drink alcoholic beverages?
Have you used heroin, cocaine, marijuana or other such drugs?
Are you pregnant?
Are you nursing?
Are you taking birth control pills?
If you have any condition, disease or problem not listed, please explain:
Have you ever had any serious trouble with any previous dental treatment?
Have you ever had an injury to the face, jaws or teeth?
Have you had any dental x-rays in the last three years?
Have you received radiation treatment to your jaws or head?
Do you ever get cold sores or canker sores?
Do you ever feel that you have a dry mouth?
Does your jaw click or pop when you chew?
Has it clicked or popped in the past when chewing?
Does your jaw hurt when you chew?
Has it hurt in the past when chewing?
Have you had a bad reaction to local anesthetics?
Are any of your teeth sensitive to sweets, hot, cold or biting?
Do any of your teeth feel loose?
Gum/periodontal treatment
Orthodontic treatment
Root canal/endodontic treatment
Wisdom tooth removal
Removal of other teeth
Are you wearing dentures or partial dentures?
If so, were they made over five years ago?
Have you had teeth replaced with a fixed (cemented) bridge?
Do you wish you had more teeth to chew with?
Are you satisfied with the appearance of your teeth?
How do you feel about going to the dentist? (no problem, apprehensive, scared)
Patient's Name:
Signature of Patient or Guardian: