Health History
Patient's Name:
Age:
Birthdate:
Name you like to be called:
Home Phone:
School:
Grade:
Address:
City:
State:
zip:
Social Security #
Do you play a musical instrument?
Yes
No
Who may we thank for referring you to our office?
RESPONSIBLE PARTY
Name:
Marital Status:
Address:
City:
State:
zip:
Address:
City:
State:
zip:
How long at this address?
Previous Address (if different):
City:
State:
zip:
Email Address
Home Phone
Cell Phone
Employer
Occupation
No. of years employed
INSURANCE INFORMATION
Insured's Name
Insured's SS#
Insurance Co
Insurance Co. Address
Group #
Phone
Insured's Employer
Do you have dual coverage?
Yes
No
Insured's Name
Insured's SS#
Insurance Co
Insurance Co. Address
Group #
Phone
Insured's Employer
MEDICAL/DENTAL HISTORY
Physician's Name:
Phone:
Dentists Name:
Phone:
Yes
No
Are you currently under any medical treatment?
Yes
No
Do you have pain, clicking, and/or popping noises in the jaw?
Yes
No
Are you aware of either clenching or grinding of teeth?
Yes
No
Do you have frequent headaches? How often?
Yes
No
Do you have ear problems? (Aches, ringing, dizziness, fullness)
Yes
No
Do you have difficulty breathing through the nose?
Yes
No
Do you have habits such as nail biting, finger or thumb sucking, lip or cheek biting?
Yes
No
Do you have speech problems, or are you in speech therapy?
Yes
No
Have you had your tonsils and/or adenoids removed?
Yes
No
Has there been any history of:
Joint swelling
Asthma
TB
Aids
kidney
liver Condition
Epilepsy
Rheumatic fever
Other major illnesses?
Yes
No
Do you bleed easily?
Yes
No
Is there a tendency to faint or become dizzy?
Yes
No
Do you have allergies? (Sulphur, penicillin, Novocain, etc.)
Yes
No
Are you currently taking any medication? List:
Yes
No
Do you have a heart condition?
Yes
No
Do you pre-medicate?
Yes
No
Cardiologist:
Yes
No
Do you have sleep apnea?
Yes
No
Do you smoke or chew tobacco?
Yes
No
Have there been any injuries to the teeth?
Yes
No
Have you had any permanent teeth extracted?
Signature
Date: