Health History Form

Patient Health History
Have you taken any medications or drugs in the past two years?  Yes   No  
Are you now taking any medications, drugs, or pills?  Yes   No  
Are you aware of being allergic to, or have you ever reacted adversely to any medication or substance? Yes   No  
Do you have a bleeding disorder, or are you taking any blood thinning medications? Yes No  
Do you or have you had any diseases, conditions, or problems not listed? Yes No
Have you been hospitalized in the last two years? Yes No
Women, are you........
Pregnant: Yes No
Nursing: Yes No
Taking birth control pills: Yes No
Do you clench or grind your teeth? Yes No
Are your jaws or teeth tired when you awaken? Yes No
Do you have pain in your jaw joint? Yes No
Are you happy with the appearance of your teeth? Yes No
Do you wish your teeth were whiter? Yes No
I understand the above information is necessary to provide me with dental care in a safe and efficient manner. I have answered all questions to the best of my knowledge. Should further information be needed, you have my permission to ask the respective health care provider or agency. I will notify the dentist of any health or medication changes. I authorize x-rays, oral exams, study models, photographs, and any other diagnostic aids deemed appropriate to make a thorough dental diagnosis. I authorize treatment, medication, and therapy that may be indicated. I understand there is a very low risk of nerve damage in the mouth from the administration and use of local anesthetics.


By checking this box, I understand and agree to the terms above.