Form Center

2. Date*
   Date
4. Reason for your visit today*
6. First name*
7. Middle name
8. Last name*
10. Date of birth*
    Date of birth
11. Sexual identity

    1. Male
    2. Female
    3. Non-binary
13. Race/Ethnicity

    1. Black or African American
    2. Asian
    3. White

    1. American Indian or Alaska Native
    2. Native Hawaiian or other Pacific Islander
    3. Other
15. Would you like an interpreter?*

    1. Yes
    2. No
16. If you checked yes, what is your preferred language?
18. Parent's name (if the patient is less than 18 years old)
20. Patient's doctor
21. Office phone number
23. Is the patient in good health?

    1. Yes
    2. No
    3. I don't know
25. if you answered no, please provide more information.
27. Has the patient

    1. Ever been hospitalized?
    2. Had general anesthesia?
    3. Visited the emergency room?
28. If you answered yes to any of these items, provide more information.
30. Is the patient taking any medications?

    1. Yes
    2. No
    3. I don't know
32. If you answered yes, please list the medications below.
34. Is the patient allergic to any foods or medications?

    1. Yes
    2. No
    3. I don't know
36. If you answered yes, please provide more information.
38. Has the patient ever had any of the following

    1. AIDS/HIV Positive
    2. Alcoholism
    3. Allergies
    4. Anemia
    5. Arthritis
    6. Asthma
    7. Autism
    8. Bone disease
    9. Cancer
    10. Chemical dependency
    11. Chest pain
    12. Circulation problems
    13. Convulsions or seizures
    14. Diabetes
    15. Emotional or behavior problems
    16. Epilepsy

    1. Excessive bleeding
    2. Frequent headaches
    3. Hospitalizations
    4. Heart disease
    5. Heart murmur
    6. Hepatitis/Liver disease
    7. Hepatitis carrier
    8. High blood pressure
    9. Kidney disease
    10. Kidney dialysis
    11. Latex sensitivity
    12. Lupus
    13. Low blood pressure
    14. Malignancies
    15. Neck or back problems
    16. Nervous problems

    1. Pacemaker
    2. Prosthetic joints
    3. Psychiatric care
    4. Radiation treatments
    5. Respiratory problems
    6. Rheumatic fever
    7. Scarlet fever
    8. Sinus problems
    9. Speech problems
    10. STD
    11. Stroke
    12. Tonsil or adenoid problems
    13. Tuberculosis
    14. Thyroid disease
    15. Ulcers
    16. Use tobacco (smoke, vape, chew)
40. Women

    1. Are you or could you be pregnant?
    2. Are you nursing?
    3. Are taking birth control pills?
41. If you are pregnant, what is your due date?
    If you are pregnant, what is your due date?
43. If you checked anything above, please give us more information.
45. I certify that I have read and understand the questions above. I acknowledge that my questions have been answered to my satisfaction. I will not hold my dentist or any other member of his/her staff responsible for any errors that I have made in the completion of this form.
47. Initials please. *

    We will get your signature during your appointment. 

48. Date*
    Date
50. Interpreter name
51. Date
    Date
55. For dental staff only
57. Health history reviewed by
58. Date
    Date
Leave This Blank:


60. 1. Receive an email copy of this form.
61. Email address

    This field is not part of the form submission.

62. Submit

* indicates a required field