Health History

1. Do you have pain from any area of your mouth?

Yes No

2. Are you in good health?

Yes No

3. My last physical examination was on

4. Are you now under the care of a physician?

Yes No

If the answer is YES, please specify below:

Physician's Name

Phone #

Address

5. Have you been hospitalized or had a serious illness within the past 5 years?

Yes No

6. Are you now taking any medication drugs or pills?

Yes No

If YES, please list those drugs

8. Are you aware of being allergic to any other medication or substance?

Yes No

If YES, please list:

10. Do you get up often at night to urinate?

Yes No

11. Are you thirsty much of the time?

Yes No

12. Has anyone in your family had diabetes?

Yes No

13. Do you consider yourself a nervous personn?

Yes No

14. Do you smoke?

Yes No

If YES, how much?

15. Do you have any disease, condition or problem not listed above that you think we should know about?

Yes No

If YES, explain:

For Women Only

Are you pregnant?

Yes No

If YES, what month?

Consent

The undersigned hereby authorizes Doctor to take radiographs, study models, photographs, or any other diagnostic aids deemed appropriate by Doctor to make a thorough diagnosis of the patient's dental needs. I also authorize Doctor to perform any and all forms of treatment, medication and therapy, that may be indicated in connection with

and further authorize and consent that Doctor choose and employ such assistance as he deems fit. I also understand the use of anesthetic agents embodies a certain risk. I understand that responsibility for payment for Dental Services provided in this office for myself or my dependents is mine, due and payable at the time services are rendered.

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Relationship to Patient

Health History Update

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