FacebookTwitterBloggerYouTubeLinkedIN
 
 





 
 

Patient Forms - Health History Form  

Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive.

If you would prefer to print out the form and bring it with you, click on the link below. Otherwise an online form has been provided below. Thank you for answering the following questions.

Health History Form (pdf)

Patient's Name
      Birth Date: 
Although dental personnel primarily treat the area in and around the mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions.
Are you currently under a physician's care for a medical condition (besides routine/annual exams)?
  Yes NoIf yes:
Have you been diagnosed with any special needs condition(s) or disorders(s)? If so, what type?
  Yes NoIf yes:
Have you ever been hospitalized or had a major operation?
  Yes NoIf yes:
Have you ever had a serious head or neck injury?
  Yes NoIf yes:
Are you taking any medications, pills, or drugs?
  Yes NoIf yes:
Do you take, or have you taken, Phen-Fen or Redux?
  Yes NoIf yes:
Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates?
  Yes NoIf yes:
Are you on a special diet?
  Yes NoIf yes:
Do you smoke or use chewing tobacco?
  Yes NoIf yes:
Do you use controlled substances?
  Yes NoIf yes:

Women: Are you
 Pregnant?  Trying to get pregnant?  Nursing?  Taking oral contraceptives?

Are you allergic to any of the following?
 Aspirin  Penicillin  Codeine  Acrylic
 Metal  Latex  Local Anesthetics  Clindamycin
 Amoxicillin  Other    

Do you have, or have you had, any of the following?
Acid Reflux  Yes  No Drug Addiction  Yes  No Low Blood Pressure  Yes  No
ADD/ADHD  Yes  No Easily Winded  Yes  No Lung Disease  Yes  No
AIDS/HIV Positive  Yes  No Emphysema  Yes  No Lupus  Yes  No
Alzheimer's Disease  Yes  No Epilepsy or Seizures  Yes  No Mitral Valve Prolapse  Yes  No
Anaphylaxis  Yes  No Excessive Bleeding  Yes  No Osteoporosis  Yes  No
Anemia  Yes  No Excessive Thirst  Yes  No Pain in Jaw Joints  Yes  No
Angina  Yes  No Fainting Spells/Dizziness  Yes  No Parathyroid Disease  Yes  No
Anxiety  Yes  No Frequent Cough  Yes  No Psychiatric Care  Yes  No
Arthritis/Gout  Yes  No Frequent Diarrhea  Yes  No Radiation Treatments  Yes  No
Artificial Heart Valve  Yes  No Frequent Headaches  Yes  No Recent Weight Loss  Yes  No
Artificial Joint  Yes  No Glaucoma  Yes  No Renal Dialysis  Yes  No
Asperger Syndrome  Yes  No Hay Fever  Yes  No Rheumatic Fever  Yes  No
Asthma  Yes  No Heart Attack/Failure  Yes  No Rheumatism  Yes  No
Autism Spectrum Disorder  Yes  No Heart Murmur  Yes  No Scarlet Fever  Yes  No
Blood Disease  Yes  No Heart Pacemaker  Yes  No Shingles  Yes  No
Blood Transfusion  Yes  No Heart Trouble/Disease  Yes  No Sickle Cell Disease  Yes  No
Breathing Problems  Yes  No Hemophilia  Yes  No Sinus Trouble  Yes  No
Bruise Easily  Yes  No Hepatitis A  Yes  No Spina Bifida  Yes  No
Cancer  Yes  No Hepatitis B or C  Yes  No Stomach/Intestinal Disease  Yes  No
Celiac Disease  Yes  No Herpes  Yes  No Stroke  Yes  No
Chemotherapy  Yes  No High Blood Pressure  Yes  No Swelling of Limbs  Yes  No
Chest Pains  Yes  No High Cholesterol  Yes  No Thyroid Disease  Yes  No
Cold Sores/Fever Blisters  Yes  No Hives or Rash  Yes  No Tonsillitis  Yes  No
Congenital Heart Disorder  Yes  No Hypoglycemia  Yes  No Tuberculosis  Yes  No
Convulsions  Yes  No Irregular Heartbeat  Yes  No Tumors or Growths  Yes  No
Cortisone Medicine  Yes  No Kidney Problems  Yes  No Ulcers  Yes  No
Crohn's Disease  Yes  No Leukemia  Yes  No Yellow Jaundice  Yes  No
Diabetes  Yes  No Liver Disease  Yes  No    
**If you have an artificial joint, do you require pre-medication for your dental appointments?
  Yes NoIf yes, please explain:
Have you ever had any serious illness not listed above?
  Yes NoIf yes, please explain:

Comments:

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in medical status.

By typing your name in the space provided below, this serves as your digital signature which affirms the information you provided is correct.

Signature of Patient, Parent, or Guardian (Please type your full name): Signature is Required.

     Date: 


 
© Copyright 2010- Dr. Matthew T. Lenz DDS, www.lenzdds.com
All Rights Reserved
Web Development, Hosting and Maintenance provided by TakeCareOfMyWebSite.com