Health History

Health History

Patient Information Record

Marital Status:
Authorization to receive text:
Authorization to receive email:

Insurance Information

Policy Holder:
Payment is due at time of service if insurance section is not completed:

Medical History

Are you now or have you been under the care of a physician during the past 5 years?
Do you take any medications regularly?
Are you taking any now?
*** Have you ever had any surgeries or hospitalizations?
Have you ever had breathing difficulty such as asthma, emphysema, chronic cough, pneumonia, tuberculosis, or any other lung disorder?
Do you smoke?
Check any of the following which you have or had in the past:
Are you allergic to ANY medications?
Have you ever had undesirable effects from taking these drugs?
Do you have popping or clicking in your jaw?
Have you had TMJ problems in the past?
Do you bleed easily or for long periods?
Do you now have a cold, cough or sinus trouble?
Do you wear contact lenses?
If female…are you pregnant?
When you walk up stairs or exercise, do you ever experience chest pain or shortness of breath or have to stop simply because you are very tired?
Do your ankles swell during the day?
Do you use more than 2 pillows to sleep?
Do you have any disease, problem, or condition not listed above?
Do you have any food allergies?
To the best of my knowledge, all of the preceding answers are true and correct. If I ever have any change in my medical history (including changes in medicine) or health, I will inform the doctor of dentistry at my next appointment.
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