Health History

Patients name? *

Patient's Date of Birth *

IF YOU HAVE ANY CHANGES TO YOUR ADDRESS, PHONE NUMBER, INSURANCE, OR ANY OTHER PERSONAL INFORMATION, PLEASE LET US KNOW!

Please list ANY/ALL hospitalization(s), serious illness(es), surgeries, etc. Especially the placement of artificial joint(s), pins/plates, stent(s), and pacemaker(s). Please list ANY health change the patient has had/any new diagnosis since the last visit.

Are you pregnant or possibly pregnant? *

Yes

No

N/A

Are you breastfeeding? *

Yes

No

N/A

Have you experienced any of these sleep-related breathing disorders: *

Mouth breathing

Snoring

Trouble breathing during sleep

None

Please list any and all allergies, including LATEX *

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

Please list ALL medications (prescription/over-the-counter) the patient is currently taking or provide a list of those medications.

IF you do not currently take any medications, click here

I do not take medication at this time

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

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

Parent or Guardian Signature *

clear

Date * +

Parent or Guardian Signature *

clear

Date * +

Parent or Guardian Signature *

clear

Date * +