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  No   If yes:

Have you been diagnosed with any special needs condition(s) or disorders(s)? If so, what type?
Yes  No   If yes:

Have you ever been hospitalized or had a major operation?
Yes  No   If yes:

Have you ever had a serious head or neck injury?
Yes  No   If yes:

Are you taking any medications, pills, or drugs?
Yes  No   If yes:

Do you take, or have you taken, Phen-Fen or Redux?
Yes  No   If yes:

Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates?
Yes  No   If yes:

Are you on a special diet?
Yes  No   If yes:

Do you smoke or use chewing tobacco?
Yes  No   If yes:

Do you use controlled substances?
Yes  No   If 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

ADD/ADHD Yes No

AIDS/HIV Positive Yes No

Alzheimer's Disease Yes No

Anaphylaxis Yes No

Anemia Yes No

Angina Yes No

Anxiety Yes No

Arthritis/Gout Yes No

Artificial Heart Valve Yes No

Artificial Joint Yes No

Asperger Syndrome Yes No

Asthma Yes No

Autism Spectrum Disorder Yes No

Blood Disease Yes No

Blood Transfusion Yes No

Breathing Problems Yes No

Bruise Easily Yes No

Cancer Yes No

Celiac Disease Yes No

Chemotherapy Yes No

Chest Pains Yes No

Cold Sores/Fever Blisters Yes No

Congenital Heart Disorder Yes No

Convulsions Yes No

Cortisone Medicine Yes No

Crohn's Disease Yes No

Diabetes Yes No

Drug Addiction Yes No

Easily Winded Yes No

Emphysema Yes No

Epilepsy or Seizures Yes No

Excessive Bleeding Yes No

Excessive Thirst Yes No

Fainting Spells/Dizziness Yes No

Frequent Cough Yes No

Frequent Diarrhea Yes No

Frequent Headaches Yes No

Glaucoma Yes No

Hay Fever Yes No

Heart Attack/Failure Yes No

Heart Murmur Yes No

Heart Pacemaker Yes No

Heart Trouble/Disease Yes No

Hemophilia Yes No

Hepatitis A Yes No

Hepatitis B or C Yes No

Herpes Yes No

High Blood Pressure Yes No

High Cholesterol Yes No

Hives or Rash Yes No

Hypoglycemia Yes No

Irregular Heartbeat Yes No

Kidney Problems Yes No

Leukemia Yes No

Liver Disease Yes No

Low Blood Pressure Yes No

Lung Disease Yes No

Lupus Yes No

Mitral Valve Prolapse Yes No

Osteoporosis Yes No

Pain in Jaw Joints Yes No

Parathyroid Disease Yes No

Psychiatric Care Yes No

Radiation Treatments Yes No

Recent Weight Loss Yes No

Renal Dialysis Yes No

Rheumatic Fever Yes No

Rheumatism Yes No

Scarlet Fever Yes No

Shingles Yes No

Sickle Cell Disease Yes No

Sinus Trouble Yes No

Spina Bifida Yes No

Stomach/Intestinal Disease Yes No

Stroke Yes No

Swelling of Limbs Yes No

Thyroid Disease Yes No

Tonsillitis Yes No

Tuberculosis Yes No

Tumors or Growths Yes No

Ulcers Yes No

Yellow Jaundice Yes No

**If you have an artificial joint, do you require pre-medication for your dental appointments?
Yes  No   If yes, please explain:

Have you ever had any serious illness not listed above?
Yes  No   If 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:

14221 Metcalf Ave
Suite 100
Overland Park, Kansas 66223

Phone: 913.851.5900
Fax: 913.851.5912

Email: info@lenzdds.com

Click here for a map and directions

Click here to Refer A Friend

Our Hours

Monday
Tuesday
Wednesday
Thursday
First Friday
of each month

8:00 a.m. - 5:00 p.m.
8:00 a.m. - 5:00 p.m.
8:00 a.m. - 5:00 p.m.
7:00 a.m. - 4:00 p.m.
7:00 a.m. - 2:00 p.m.

Patient Forms - Health History Form

14221 Metcalf Ave Suite 100 Overland Park, Kansas 66223 Phone: 913.851.5900 Fax: 913.851.5912 Email: info@lenzdds.com

Click here for a map and directions

Click here to Refer A Friend

Our Hours

14221 Metcalf Ave
Suite 100
Overland Park, Kansas 66223

Phone: 913.851.5900
Fax: 913.851.5912

Email: info@lenzdds.com