Health History Form

Welcome to

Flushing Family Dentistry!

The benefits of a happy, healthy smile are immeasurable! Our goal is to help you reach and maintain maximum oral health. Please fill out this form completely. The better we communicate, the better we can care for you.

Spouse/Parent Information

Name:

Check One: Spouse Parent Guardian

Birth Date:

Work #:

Ext:

Person responsible for account:

Relation:

Billing Address:

Work #:

Ext:

Home #:

Dental Insurance Information

PRIMARY

Dental Coverage: Yes No

Ins. Co. Name:

Insured’s Name:

Relation:

SS#:

ID#:

Birthdate:

Employer:

SECONDARY

Dental Coverage: Yes No

Ins. Co. Name:

Insured’s Name:

Relation:

SS#:

ID#:

Birthdate:

Employer:

Medical History Information

Do you have a primary care physician? Yes No

Physician:

Phone:

Last Visit:

Previous Dentist:

Phone:

Last Visit:

Preferred Pharmacy:

Address:

In case of emergency, is there someone nearby we can contact?

Name:

Relation:

Home #:

Work #:

Cell #:

Medical History

Check any of the following that you have had or have at the present:

Other:

Major surgeries last 2 years (type and year):

Yes No

Have you been hospitalized during the past two years?

Yes No

Have you been asked by your medical doctor to premedicate before any dental treatment?

Yes No

Do you smoke or use chewing tobacco?

If Yes, How many packs per day?

Yes No

Do you smoke or ingest marijuana?

Yes No

Do you drink alcohol?

If yes:

Occasionally Weekly Daily

For Women Only:

Yes No

Are you pregnant?

If yes, due date:

Yes No

Are you taking birth control pills?

Yes No

Could you be pregnant?

Yes No

Are you nursing?

Please list all medications you are currently taking, including prescription drugs, over-the-counter drugs, vitamins, herbal remedies and supplements. (If you have a list, please present list)

Dental History

Why have you come to the dentist today?

Are you currently in pain? Yes No

Location of pain:

Have you had a serious/difficult problem associated with past dental work? Yes No

Do you now or have you ever experienced pain/discomfort in your jaw joint (TMJ/TMD)? Yes No

Do you grind/clinch your teeth? Yes No

Do you snore or have sleep apnea? Yes No

Have you had braces or Invisalign before? Yes No

Have you had oral surgery before? Yes No

Have you had deep cleaning or gum surgery? Yes No

Do you have severe anxiety with dental work? Yes No

Do you feel you have a dry mouth? Yes No

Have you had a difficulty becoming numb before? Yes No

Have you had a reaction to dental anesthetic before? Yes No

In the past, have you required antibiotics before dental treatment? Yes No

Reason antibiotic prophylaxis required:

Are you happy with your smile? Yes No

Would you like whiter teeth? Yes No

Would you like fresher breath? Yes No

How many times a day do you brush?

How many times a week do you floss?

Informed Consent

I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence according to HIPAA regulations and it is my responsibility to inform this office of any changes in my medical status.

I also understand that if this office accepts my dental insurance, I am responsible for payment of my co-pay in full for services rendered the day of service. I also understand that I am responsible for payment of any deductibles and payments that my insurance does not cover.

I authorize the dental staff to perform any necessary dental services that I may need during diagnosis and treatment with my informed consent.

Signature:

Date:

Welcome to

Flushing Family Dentistry!

Personal Information

Spouse/Parent Information

Dental Insurance Information

PRIMARY

SECONDARY

Medical History Information

In case of emergency, is there someone nearby we can contact?

Medical History

For Women Only:

Are you allergic or have you reacted adversely to any of the following (check all that apply):

Please list all medications you are currently taking, including prescription drugs, over-the-counter drugs, vitamins, herbal remedies and supplements. (If you have a list, please present list)

Dental History

Informed Consent