Health History Form
LITTLE HOUSE DENTISTRY
PATIENT INFORMATION
Welcome to our office! To assist us in serving you, please complete the following confidential form.
Patient's name ____________________________________________ Preferred name __________________ Birth date___________
Home phone ______________ Cell phone ______________ Email__________________________________________
Mailing address _________________________________________ City ____________________State ________ Zip ___________
Employer ____________________________________ Occupation ___________________________________________________
Emergency contact name ______________________Emergency Contact Number ___________________________ Relationship____________
Whom may we thank for referring you to our office? ____________________________________________________
Insurance Information: ( Not covered by dental insurance
Your Social Security number: _____________________
Dental Insurance Co.____________________________ Group #___________________ ID #_____________________
Are you the insurance subscriber? ( yes ( no
Insurance Subscriber’s birth date ______________________ Subscriber’s Social Security number __________________________
Medical Health History
(Please check any that apply)
Heart Problems
❑ Heart attack Date: ___________
❑ History of heart surgery Date:____________
❑ High blood pressure
❑ Heart murmur
❑ Heart valve problem
❑ Taking heart medication
❑ Rheumatic fever
❑ Pacemaker
Bone or Joint Problems
❑ Arthritis
❑ Joint replacement Date:___________
Has a physician recommended antibiotic premedication for your dental appointments?
( yes ( no
Blood problems
❑ Easy bruising
❑ Abnormal Bleeding
❑ Blood disease
❑ Blood transfusion
❑ HIV-positive/AIDS
Allergy problems
❑ Hay fever/ Asthma
❑ Sinus problems
❑ Taking allergy medication
Intestinal Problems
❑ Ulcers
❑ Special diet ____________
❑ Constipation or diarrhea
Tobacco use
❑ Smoking
❑ Smokeless (chewing, dipping, vaping, etc.)
❑ Past use and approximate quit date _________
Do any of the following apply?
❑ Type I or type II diabetes
❑ Family history of diabetes
❑ Stroke Date:___________
❑ History of drug or alcohol abuse
❑ Fainting spells, seizures or epilepsy
❑ Respiratory disease (tuberculosis, COPD, other)
❑ Thyroid problems
❑ Cancer or tumor
❑ Pregnant
❑ Nursing
Allergies
Are you allergic to, or have you reacted adversely to any of the following?
❑ Penicillin, Sulfa, or other antibiotics
❑ Local anesthetics
❑ Codeine or other narcotics
❑ Barbiturates, sedatives, or sleeping pills
❑ Aspirin, Acetaminophen, or Ibuprofen
❑ Metals
❑ Latex
❑ Other:___________________
How are you feeling today? ________________________________ Date_________________
List of current medications and those taken within the last year
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
Have you had surgery or been hospitalized in the last year? ( yes ( no
_______________________________________________________________________________________________________
Name and phone number of your physician_________________________________________________________________
____________________________________________________________________________________________________________________________
Dental Health History
How long has it been since your last cleaning and exam?
How often do you brush? ____________________________
How often do you floss? _____________________________
Do you have dry mouth?
( yes ( no
Are you apprehensive about dental treatment?
( yes ( no
Have you had problems with previous dental treatment? ( yes ( no
Are you satisfied with the appearance of your teeth?
( yes ( no
Do you avoid brushing part of your mouth due to pain? ( yes ( no
Do you gag easily?
( yes ( no
Do you wear dentures or partials?
( yes ( no
Do you have difficulty chewing or do you chew on only one side of your mouth?
( yes ( no
Do your gums feel swollen, tender, or bleed?
( yes ( no
Have you ever noticed slow-healing sores in or around your mouth? ( yes ( no
Are your teeth sensitive to any of the following:
Hot ? ( yes ( no
Cold? ( yes ( no
Sweets? ( yes ( no
Pressure? ( yes ( no
Do you have airway/sleep issues or have you been diagnosed with sleep apnea? ( yes ( no
Do you snore? ( yes ( no
Do you wear a night guard? ( yes ( no
Are you aware of an uncomfortable bite?
( yes ( no
Have you had a blow to the jaw (trauma)?
( yes ( no
Do you have any jaw symptoms or headaches upon waking up in the morning? ( yes ( no
Do you have pain in the face, ear, jaws, joints, throat, neck or temples? ( yes ( no
Do you have difficulty opening your mouth?
( yes ( no
Does your jaw make noise when eating or opening?
( yes ( no
Do you clench or grind your teeth?
( yes ( no
Signature of patient or guardian: _______________________________________ Date: ____________________
Dr. Signature______________________ Date__________
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