Health History
Individual form for health history
Patient Name
Mr/Dr/Mrs/Ms
First Name
Middle Name
Last Name
Preferred Name
Check all of the following that you may have had in the past or that currently apply to you:
AIDS/HIV Positive
Alzheimer's Disease
Anemia
Angina
Arthritis
Artificial Joint
Asthma
Atrial Fibrillation
Blood Disease
Blood Transfusion
Bruise Easily
Cancer*
Chemotherapy
Chest Pains
Cognitive Disorders
Cold Sores/Fever Blisters
Congenital Heart Disease
Dementia
Diabetes*
Elevated Cholesterol
Emphysema/COPD
Epilepsy or Seizures
Excessive Bleeding
Fainting/Dizzy Spells
Glaucoma
Gout
Heart Attack*
Heart Disease
Heart Murmur
Hemophilia
Hepatitis A, B, or C
Herpes
High Blood Pressure
Irregular Heartbeat
Kidney Problem/Disease
Liver Problem/Disease
Low Blood Pressure
Lung Disease
Mitral Valve Prolapse
Pacemaker/Defibrillator
Parathyroid Disease
Psychiatric Care
Radiation Treatment
Renal Dialysis
Rheumatic Fever
Scarlet Fever
Shingles
Sickle Cell Disease
Sinus Trouble/Infections
Sleep Apnea-CPAP
Sores/Growths in Mouth
Stroke
Thyroid Disease
Tuberculosis
Tumors or Growths
Ulcer
Others*
This field is required.
*If you've selected Cancer, Diabetes (A1C), Heart Attack, or Other, please provide more details:
Are you allergic to or have you reacted adversely to any of the following medications? Please check all that apply.
Aspirin
Erythromycin
Tetracycline
Codeine
Latex
Penicillin/Amoxicillin
Sulfa
Local Anesthetic
This field is required.
Other:
Have you ever taken any of the following medications? Please check all that apply, and provide start/end dates.
Actonel
Boniva
Risedronate
Alentronate
Fosamax
Zometa
Aredia
Reclast
Prolia/Denosumab
Herbal Supplements
This field is required.
Are you currently taking any medications? If yes, please list:
Do you need antibiotics prior to receiving dental care? If so, which type/dosage?
Do you take Coumadin or Plavix or any other blood thinner? If yes, do you know your typical INR?
Type a single choice question
Excellent
Good
Fair
Poor
Don't Know
This field is required.
When was your last visit with your primary care physician?
Are you currently under a physician’s care? If yes, please list reason:
Has there been any change in your general health in the past year? If yes, please explain:
Please list any other serious illness, hospitalization, or condition in the last 5 years if not listed above:
Are you a past or present smoker/vaper?
Yes
No
This field is required.
If yes, how many cigarettes/cigars/mg per day?
Do you have any history of substance abuse, or do you currently use recreational drugs?
Yes
No
This field is required.
Signature
Clear
Signature is mandatory.
Submit
Health History | Individual form for health history