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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