Health History

Patients name? *

Patient's Social Security Number *

Current Medications

	Name of Medication	Dosage	Frequency	Reason for taking
1	Name of Medication	Dosage	Frequency	Reason for taking
2	Name of Medication	Dosage	Frequency	Reason for taking
3	Name of Medication	Dosage	Frequency	Reason for taking
4	Name of Medication	Dosage	Frequency	Reason for taking
5	Name of Medication	Dosage	Frequency	Reason for taking
6	Name of Medication	Dosage	Frequency	Reason for taking
7	Name of Medication	Dosage	Frequency	Reason for taking

Please list ALL/ ANY hospitalizations, serious illnesses, surgeries, especially the placement of artificial joints, pins and plates, stents, and pacemakers. Please list ANY health change the patient has had since the last visit. *

Are you (women)?

Yes

No

N/A

Are you breastfeeding (women)?

Yes

No

N/A

Please list any and all allergies, including LATEX *

Please list any concerns/ problems/discomfort you want addressed by the hygienist or dentist *

Parent or Guardian Signature *

clear

Date * +

I have reviewed and verified the information above and made the necessary changes.

	Signature	Date	Staff initials
1	Signature	Date	Staff initials
2	Signature	Date	Staff initials
3	Signature	Date	Staff initials
4	Signature	Date	Staff initials
5	Signature	Date	Staff initials