Health History Form
Email: Today’s Date:
As required by law, our office adheres to written policies and procedures to protect the privacy of information about you that we create, receive or maintain. Your answers are for our
records only and will be kept confidential subject to applicable laws. Please note that you will be asked some questions about your responses to this questionnaire and there may be
additional questions concerning your health. This information is vital to allow us to provide appropriate care for you. This office does not use this information to discriminate.
Name: Home Phone:
Include area code Business/Cell Phone: Include area code
Last First Middle ( ) ( )
Address: City: State: Zip:
Mailing address
Occupation: Height: Weight: Date of Birth: Sex: M F
SS# or Patient ID: Emergency Contact: Relationship: Home Phone:
Include area code Cell Phone: Include area code
( ) ( )
If you are completing this form for another person, what is your relationship to that person?
Your Name Relationship
Do you have any of the following diseases or problems: (Check DK if you Don’t Know the answer to the the question) Yes No DK
Active Tuberculosis .....................................................................................................................................................................................................................................................
Persistent cough greater than a 3 week duration .....................................................................................................................................................................................................
Cough that produces blood ........................................................................................................................................................................................................................................
Been exposed to anyone with tuberculosis ...............................................................................................................................................................................................................
If you answer yes to any of the 4 items above, please stop and return this form to the receptionist.
Dental Information For the following questions, please mark (X) your responses to the following questions.
What is the reason for your dental visit today?
How do you feel about your smile?
Medical Information Please mark (X) your response to indicate if you have or have not had any of the following diseases or problems.
Yes No DK
Do your gums bleed when you brush or floss? ...................................................
Are your teeth sensitive to cold, hot, sweets or pressure? ................................
Is your mouth dry? ...............................................................................................
Have you had any periodontal (gum) treatments? .............................................
Have you ever had orthodontic (braces) treatment? .........................................
Have you had any problems associated with previous dental treatment? .........
Is your home water supply fluoridated? ..............................................................
Do you drink bottled or filtered water? ...............................................................
If yes, how often? Circle one: DAILY / WEEKLY / OCCASIONALLY
Are you currently experiencing dental pain or discomfort?.....................
Yes No DK
Are you now under the care of a physician? .......................................................
Physician Name: Phone: Include area code
( )
Address/City/State/Zip:
Are you in good health? .......................................................................................
Has there been any change in your general health within the past year? ..........
If yes, what condition is being treated?
Date of last physical exam:
© 2012 American Dental Association
Form S500
Yes No DK
Do you have earaches or neck pains?..................................................................
Do you have any clicking, popping or discomfort in the jaw? ............................
Do you brux or grind your teeth? ........................................................................
Do you have sores or ulcers in your mouth? .......................................................
Do you wear dentures or partials? ......................................................................
Do you participate in active recreational activities? ...........................................
Have you ever had a serious injury to your head or mouth? ..............................
Date of your last dental exam:
What was done at that time?
Date of last dental x-rays:
Yes No DK
Have you had a serious illness, operation or been hospitalized
in the past 5 years? ..............................................................................................
If yes, what was the illness or problem?
Are you taking or have you recently taken any prescription
or over the counter medicine(s)? ........................................................................
If so, please list all, including vitamins, natural or herbal preparations
and/or dietary supplements:
Medical Information
Please mark (X) your response to indicate if you have or have not had any of the following diseases or problems.
NOTE: Both doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment.
I certify that I have read and understand the above and that the information given on this form is accurate. I understand the importance of a truthful health history and that my
dentist and his/her staff will rely on this information for treating me. I acknowledge that my questions, if any, about inquiries set forth above have been answered to my satisfaction.
I will not hold my dentist, or any other member of his/her staff, responsible for any action they take or do not take because of errors or omissions that I may have made in the
completion of this form.
Signature of Patient/Legal Guardian: Date:
Signature of Dentist: Date:
Has a physician or previous dentist recommended that you take antibiotics prior to your dental treatment? ......................................................................................................
Name of physician or dentist making recommendation: Phone: Include area code
( )
Do you have any disease, condition, or problem not listed above that you think I should know about? ................................................................................................................
Please explain:
(Check DK if you Don’t Know the answer to the question) Yes No DK
Do you wear contact lenses? ...............................................................................
Joint Replacement. Have you had an orthopedic total joint
(hip, knee, elbow, finger) replacement? ..............................................................
Date: __________________ If yes, have you had any complications? __________________________
Are you taking or scheduled to begin taking an antiresorptive agent
(like Fosamax
®
, Actonel
®
, Atelvia, Boniva
®
, Reclast, Prolia) for
osteoporosis or Paget’s disease? .........................................................................
Since 2001, were you treated or are you presently scheduled to begin
treatment with an antiresorptive agent (like Aredia
®
, Zometa
®
, XGEVA)
for bone pain, hypercalcemia or skeletal complications resulting from
Paget’s disease, multiple myeloma or metastatic cancer? ..................................
Date Treatm e nt b e gan: _____________________________________________________________________
Yes No DK
Do you use controlled substances (drugs)? ........................................................
Do you use tobacco (smoking, snuff, chew, bidis)? ............................................
If so, how interested are you in stopping?
Circle one: VERY / SOMEWHAT / NOT INTERESTED
Do you drink alcoholic beverages? ......................................................................
If yes, how much alcohol did you drink in the last 24 hours? _______________________________
If yes, how much do you typically drink i n a week? _________________________________________
WOMEN ONLY Are you:
Pregnant? ............................................................................................................. n n n
Num b er of weeks : ______________________
Taking birth control pills or hormonal replacement? ........................................... n n n
Nursing? ............................................................................................................... n n n
FOR COMPLETION BY DENTIST
Comments:
Allergies. Are you allergic to or have you had a reaction to:
To all yes responses, specify type of reaction. Yes No DK
Local anesthetics ___________________________________________________________________
Aspirin _______________________________________________________________________________
Penicillin or other antibiotics _______________________________________________________
Barbiturates, sedatives, or sleeping pills __________________________________________
Sulfa drugs __________________________________________________________________________
Codeine or other narcotics ________________________________________________________
Please mark (X) your response to indicate if you have or have not had any of the following diseases or problems.
Yes No DK
Metals _______________________________________________________________________________
Latex (rubber) ______________________________________________________________________
Iodine ________________________________________________________________________________
Hay fever/seasonal _________________________________________________________________
Animals ______________________________________________________________________________
Food _________________________________________________________________________________
Other ________________________________________________________________________________
Yes No DK
Cardiovascular disease ..........
Angina ....................................
Arteriosclerosis ......................
Congestive heart failure ........
Damaged heart valves ..........
Heart attack ..........................
Heart murmur ........................
Low blood pressure ...............
High blood pressure ...............
Other congenital
heart defects .........................
Yes No DK
Mitral valve prolapse ...............
Pacemaker ...............................
Rheumatic fever ......................
Rheumatic heart disease.........
Abnormal bleeding ..................
Anemia ....................................
Blood transfusion ....................
If yes, date:_______________________________
Hemophilia ..............................
AIDS or HIV infection ..............
Arthritis ...................................
Yes No DK
Autoimmune disease ...............
Rheumatoid arthritis ...............
Systemic lupus
erythematosus ........................
Asthma ....................................
Bronchitis ................................
Emphysema .............................
Sinus trouble ...........................
Tuberculosis .............................
Cancer/Chemotherapy/
Radiation Treatment................
Chest pain upon exertion ........
Chronic pain ............................
Diabetes Type I or II ...............
Eating disorder ........................
Malnutrition ............................
Gastrointestinal disease ..........
G.E. Reflux/persistent
heartburn ................................
Ulcers ......................................
Thyroid problems ....................
Stroke ......................................
Yes No DK
Glaucoma ................................
Hepatitis, jaundice or
liver disease .............................
Epilepsy ...................................
Fainting spells or seizures .......
Neurological disorders ............
If yes, specify:____________________________
Sleep disorder .........................
Do you snore? .........................
Mental health disorders ..........
Spe c if y : __________________________________
Recurrent Infections ...............
Type of infection: _________________________
Kidney problems......................
Night sweats ...........................
Osteoporosis ...........................
Persistent swollen glands
in neck .....................................
Severe headaches/
migraines .................................
Severe or rapid weight loss ....
Sexually transmitted disease . .
Excessive urination .................
Yes No DK
Artificial (prosthetic) heart valve .........................................................................
Previous infective endocarditis ............................................................................
Damaged valves in transplanted heart ................................................................
Congenital heart disease (CHD)
Unrepaired, cyanotic CHD ............................................................................
Repaired (completely) in last 6 months .......................................................
Repaired CHD with residual defects ............................................................
Except for the conditions listed above, antibiotic prophylaxis is no longer recommended
for any other form of CHD.