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Dr. John McEntire
Dr. Teri Marek
Dr. Keely Long
Dr. Tyler Birk
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Health History Form
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Indicates required field
First Name
*
Middle Initial
*
Last Name
*
Address
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Line 1
Line 2
City
State
Zip Code
Country
Cell
*
Home Phone
*
Work Phone
*
May we contact you at work?
*
Yes
No
Email
*
Birth Date (01/01/1999)
*
Sex
*
Male
Female
Employer
*
Social Security Number
*
Emergency Contact Name
*
First
Last
Emergency Contact Number
*
How did you hear about our office?
*
When was your last dental visit?
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Are you currently in pain?
*
How can we help improve your health?
*
Have you ever had any injuries to your teeth, jaw, or face?
*
Do you have any anxiety towards dental care?
*
Is there anything you would like to change about your smile?
*
Do your gums ever bleed?
*
Yes
No
Do you grind your teeth?
*
Yes
No
Do you use tobacco products?
*
Yes
No
Are your teeth ever sensitive?
*
Yes
No
Please check all that you currently have, or have ever had
Lung Health
*
asthma
emphysema
tuberculosis (tb)
Blood Health
*
stroke
excessive bleeding
leukemia
Heart Health
*
heart attack
heart surgery
pace maker
vale replacement
high blood pressure
infective endocarditis
Endocrine
*
diabetes
thyroid disease
Immune Health
*
HIV/AIDS
hepatitis
Skeletal
*
osteoporosis
joint replacement
Are you allergic to, or have you ever had an adverse reaction to any of the following?
*
amoxicillin
penicillin
local anesthetics
latex
other
Other
*
seizures
cancer
fainting
chemotherapy
anxiety
radiation therapy
Please list additional health problems
*
Please list any medications you are taking
*
Please list any surgeries
*
Height
*
Weight
*
Females: Are you pregnant?
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Yes
No
I have completed this form to the best of my knowledge. I give permission for Hutto Premier Dentistry to take any necessary diagnostic x-rays, photos, or study models required to enable complete diagnosis and treatment. Should I refuse to take any necessary x-rays, I understand I may not receive treatment.
*
Yes
No
Submit
Home
Our Team
Dr. John McEntire
Dr. Teri Marek
Dr. Keely Long
Dr. Tyler Birk
Front Office Team
Dental Hygienists
Dental Assistants
Our Office
Amenities
Policies
Testimonials
Video Tour
Dental Services
Financing
CEREC Crowns
Sedation
Dental Implants
Orthodontics
Cosmetic Dentistry
Pediatric Dentistry
Wisdom Teeth
Preventive Care
Digital X-Rays
Schedule Appointment
Appointment Forms