Dental Treatment Consent & Health History Form

E-mail*

example@example.com

Today's Date*

Date

As required by law, our office adheres to written policies and procedures to protect the privacy of information about you that we create, receive or maintain. Your
answers are for our records only and will be kept confidential subject to applicable laws. Please note that you will be asked some questions about your responses to this questionnaire and there may be additional questions concerning your health. This information is vital to allow us to provide appropriate care for you. This office
does not use this information to discriminate.

Name*

First NameMiddle InitialLast Name

Home Phone

Please enter a valid phone number.

Cell Phone*

Please enter a valid phone number.

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Occupation*

Height*

Weight*

Date of birth*

Date

Sex*

MaleFemale

Social Security #

Emergency Contact*

First NameLast Name

Relationship*

Phone Number*

Please enter a valid phone number.

If you are completing this form for another person, what is your relationship to that person?

Name

Name of person filling out this form

Do you have any of the following diseases or problems:*

	Yes	No	Don't know
Active Tuberculosis
Persistent cough greater than a 3 week duration
Cough that produces blood
Been exposed to anyone with tuberculosis

Dental Information*

	Yes	No	Don't Know
Do your gums bleed when you brush or floss?
Are your teeth sensitive to cold, hot, sweets or pressure?
Does food or floss catch between your teeth?
Is your mouth dry?
Have you had any periodontal (gum) treatments?
Have you ever had orthodontic (braces) treatment?
Have you had any problems associated with previous dental treatment?
Is your home water supply fluoridated?
Are you currently experiencing dental pain or discomfort?
Do you have earaches or neck pains?
Do you have any clicking, popping or discomfort in the jaw?
Do you brux or grind your teeth?
Do you have sores or ulcers in your mouth?
Do you wear dentures or partials?
Do you participate in active recreational activities?
Have you ever had a serious injury to your head or mouth?
Do you drink bottled or filtered water?

If yes to drinking bottled or filtered water, how often?

DailyWeeklyOccasionally

Date of your last dental exam:*

Date

What was done at that time?*

Date of last dental x-rays:*

Date

What is the reason for your dental visit today?*

How do you feel about your smile?*

Are you now under the care of a physician?*

YesNoDon't know

Physician Name*

Phone Number*

Please enter a valid phone number.

Address*

Street Address

CityState / Province

Postal / Zip Code

Are you in good health?*

YesNoDon't know

Has there been any change in your general health within the past year?*

YesNoDon't know

If yes, what condition is being treated?*

Date of last physical exam:*

Date

Have you had a serious illness, operation or been hospitalized in the past 5 years?*

YesNoDon't know

If yes, what was the illness or problem?*

Are you taking or have you recently taken any prescription or over the counter medicine(s)?*

YesNoDon't know

If so, please list all, including vitamins, natural or herbal preparations and/or diet supplements:*

	Yes	No	Don't Know
Do you wear contact lenses?
Are you taking or scheduled to begin taking either of the medications, alendronate (Fosamax) or risedronate (Actonel) for osteoporosis or Paget's disease?
Do you use controlled substances (drugs)?

Joint Replacement: Have you had an orthopedic total joint (hip, knee, elbow, finger) replacement?*

YesNoDon't know

If yes, date of replacement:*

Date

If yes, have you had any complications?*

Since 2001, were you treated or are you presently scheduled to begin treatment with the intravenous bisphosphonates (Aredia or Zometa) for bone pain, hypercalcemia or skeletal complications resulting from Paget's disease, multiple myeloma or metastatic cancer?*

YesNoDon't know

If yes, date treatment began:*

Date

Do you use tobacco (smoking, snuff, chew, bidis)?*

YesNoDon't know

If yes, how interested are you in stopping?*

VerySomewhatNot interested

Do you drink alcoholic beverages?*

YesNoDon't know

If yes, how much alcohol did you drink in the last 24 hours?*

If yes, how much do you typically drink in a week?*

WOMEN ONLY

	Yes	No	Don't Know
Taking birth control pills or hormonal replacement?
Nursing?
Pregnant?

If yes to Pregnant, number of weeks?

Local Anesthetics*

YesNoDon't know

Reaction to Local Anesthetics:*

Aspirin*

YesNoDon't know

Reaction to Aspirin:*

Penicillin or other antibiotics*

YesNoDon't know

Reaction to Penicillin or other antibiotics:*

Barbiturates, sedatives, or sleeping pills*

YesNoDon't know

Reaction to Barbiturates, sedatives, or sleeping pills:*

Sulfa drugs*

YesNoDon't know

Reaction to Sulfa drugs:*

Codeine or other narcotics*

YesNoDon't know

Reaction to Codeine or other narcotics:*

Metals*

YesNoDon't know

Reaction to Metals:*

Latex (rubber)*

YesNoDon't know

Reaction to latex (rubber):*

Iodine*

YesNoDon't know

Reaction to Iodine:*

Hay fever/seasonal*

YesNoDon't know

Reaction to Hay fever/seasonal:*

Animals*

YesNoDon't know

Reaction to animals:*

Food*

YesNoDon't know

Reaction to food:*

Other*

YesNoDon't know

Reaction to other things:*

Please mark your response to indicate if you have or have not had any of the following diseases or problems: Except for the conditions listed above, antibiotic prophylaxis is no longer recommended for any other form of CHD.*

	Yes	No	Don't Know
Artificial (prosthetic) heart valve
Previous infective endocarditis
Damaged valves in transplanted heart
Unrepaired, cyanotic CHD
Repaired CHD with residual defects
Cardiovascular disease
Angina
Arteriosclerosis
Congestive heart failure
Damaged heart valves
Heart attack
Heart murmur
Low blood pressure
High blood pressure
Other congenital heart defects
Mitral valve prolapse
Pacemaker
Rheumatic fever
Rheumatic heart disease
Abnormal bleeding
Anemia
Hemophilia
AIDS or HIV infection
Arthritis
Autoimmune disease
Rheumatoid arthritis
Systemic lupus erythematosus
Asthma
Bronchitis
Emphysema
Sinus trouble
Tuberculosis
Cancer/Chemotherapy/Radiation Treatment
Chest pain upon exertion
Chronic pain
Diabetes Type 1 or 2
Eating disorder
Malnutrition
Gastrointestinal disease
G.E. Reflux/persistent heartburn
Ulcers
Thyroid problems
Stroke
Glaucoma
Hepatitis, jaundice or liver disease
Epilepsy
Fainting spells or seizures
Sleep disorder
Kidney problems
Night sweats
Osteoporosis
Persistent swollen glands in neck
Severe headaches/migraines
Severe or rapid weight loss
Sexually transmitted disease
Excessive urination
Repaired(completely) in last 6 months

Blood transfusion*

YesNoDon't know

If yes, date:*

Date

Neurological disorders*

YesNoDon't know

If yes, specify:*

Mental health disorders*

YesNoDon't know

If yes, specify: *

Recurrent Infections*

YesNoDon't know

Type of infection:*

Has a physician or previous dentist recommended that you take antibiotics prior to your dental treatment?*

YesNoDon't know

Name of physician or dentist making recommendation:*

Phone Number*

Please enter a valid phone number.

Do you have any disease, condition, or problem not listed above that you think I should know about?*

YesNoDon't know

If yes, please explain:*

NOTE: Both Doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment.
I certify that I have read and understand the above and that the information given on this form is accurate. I understand the importance of a truthful health history and that my dentist and his!her staff will rely on this information for treating me. I acknowledge that my questions, if any, about inquiries set forth above have been answered to my satisfaction. I will not hold my dentist, or any other member of his!her staff, responsible for any action they take or do not take because of errors or omissions that I may have made in the completion of this form.

Signature*

Date*

Date

AUTHORIZATION FOR DENTAL TREATMENT

Health History Form