Health History Form

Health History

Please provide us with your health history information. Please fill out as much as possible.

Do you currently have a physician who oversees your health and medical needs?

Your current physical health is…

Physician’s Name

Physician’s Phone Number

Physician’s Address

When was your last visit to a physician?

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

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

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

If so, what condition was being treated?

Are you taking or scheduled to begin taking either of the medications, alendronate (Fosamax®) or risedronate (Actonel®) for osteoporosis or Paget’s disease?

If so, what condition was being treated, and for how long?

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?

If so, what condition was being treated, and for how long?

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

Do you use controlled substances (drugs)?

Do you drink alcoholic beverages?

If you marked any of the boxes above, please provide more details about the conditions you have or have had.

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 the 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.

First Name

Last Name

Today’s Date

Health History Form for Dental Patients

Health History