(248) 634-9251
(248) 634-9251

Health History Form

Fill Out Our Confidential Health History Form Below

"*" indicates required fields

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I. Click Appropriate Answer

1. Is your general health good?*
2. Has there been any change in your health within the last year?*
3. Have you gone to the hospital or emergency room or had a serious illness in the last three years?*
4. Are you being treated by a physician now?*
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5. Have you had problems with prior dental treatment?*
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6. Are you in pain now?*

II. Have you ever experienced or had any of the following?

Chest pain (angina):*
Heart disease:*
Stroke:*
Persistent cough:*
Family history of heart disease:*
Eating disorders:*
Bleeding problems:*
Heart attack:*
Osteoporsis:*
Bruise easily:*
Heart defect:*
Hepatitis:*
Frequent headaches:*
Artificial joint:*
Sexually transmitted disease:*
Sinus problems:*
Artificial heart valve:*
Herpes:*
Frequent vomiting:*
Diabetes:*
Canker or cold sores:*
Dry mouth:*
Family history of diabetes:*
Anemia:*
Excessive thirst:*
Tumors or cancer:*
Liver disease:*
Difficulty swallowing:*
Chemotherapy:*
Transplants:*
Shortness of breath:*
Radiation:*
Tuberculosis:*
Gum disease:*
This information will not be released unless specifically authorized by the patient.
AIDS/HIV:*
Anxiety:*
Depression:*
Treatment for emotional condition:*

III. Are you allergic to or have you had a reaction to any of the following?

Codeine:*
Valium:*
Sulfa drugs:*
Local anesthetic:*
Penicillin:*
Latex:*

IV. Are you taking or have you taken any of the following in the last three months?

Recreational drugs:*
Tobacco in any form:*
Antibiotics:*
Over-the-counter medicines:*
Alcohol:*
Supplements:*
Weight loss medications:*
Bisphosphanate (Fosamax):*
Aspirin:*
Cortico-streroids:*
Blood thinners:*

V. Women only

Are you or could you be pregnant?
Are you nursing?
Are you taking birth control pills?

VI. All patients

Do you or have you had any other diseases or medical problems NOT listed on this form?*
Have you ever been pre-medicated (antibiotics) for dental treatment?*
Is there any other issue or condition that you would like to discuss with the dentist in private?*

The practice of dentistry involves treating the whole person. If the dentist determines that there may be a potential medically-compromised situation, medical consultation may be needed prior to commencement of dental treatment.

I authorize the dentist to contact my physician.

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I certify that I have read and understand this form. To the best of my knowledge, I have answered every question completely and accurately. I will inform my dentist of any change in my health and/or medication. Further, I will not hold my dentist, or any other member of his/her staff, responsible for any errors or omissions that I may have made in the completion of this form.

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Medical Updates

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Wed-Thu: 8am-5pm