Okemos Family Dentistry
Health History
Date:
Name:
Date of Birth
Name and phone of Physician:
Date of last cleaning:
Preferred Pharmacy:
Phone:
Emergency Contact:
Phone:
Relationship:
Do you smoke or use tobacco?:
Yes
No
Are you pregnant?:
Yes
No
Have you had abnormal bleeding with extractions/surgery/trauma?
Yes
No
Please explain:
Are you allergic to or have you had any reactions to the following?
No known allergies
Anesthetics
Aspirin
Latex
Metals
Penicillin
Nuts/Tree nuts
Sedatives
Sulfa drugs
Other
Have you had any of the following? Check all that apply:
ADD
ADHD
Afib
Aids or HIV
Anemia
Angina
Anxiety
Arthritis
Artificial Joints
(Pre-med required?
Y
/
N
)
Asthma
Autism Spectrum
Cancer
Cardiac Pacemaker
Chemotherapy
Cold Sores
Depression
Diabetes
(Type 1 / Type 2)
A1C & date
Epilepsy
Fainting Spells
Heart Attack
Heart Disease
Heart Murmur
Hepatitis
Hyperthyroidism
Hypothyroidism
High Blood Pressure
Inflammatory Rheumatism
Kidney Disease
Mental Disorder
Mitral Valve Prolapse
Orthodontics
Osteoporosis
(Treated with bisphosphonates?
Y
/
N
)
Periodontal Treatment
Radiation Therapy
Rheumatic Fever
Stroke
Sleep Apnea
TMJ
Tuberculosis
Venereal Disease
Other
Signature of patient
Date
Signature of doctor
Date
Date:
Name:
Date of Birth
Current medications
(Include vitamins, herbs and over the counter medications)
None
Surgical History
: List all operations/hospitalizations last 5 years
None
Dental History
: please circle any that apply
Implants
Dentures
Partials
Extractions
Orthodontics
Periodontal Surgery
History of scaling and root planning
TMJ
Occlusal guard
Sleep appliance to treat sleep apnea
Tooth sensitivity
Are you happy with your smile?
Y
/
N
If no, what would you like to change?:
Patient Initals
Doctor Initals