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: