Health History Online Form

First Name *

Middle Initial *

Last Name *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Cell *

Home Phone *

Work Phone *

May we contact you at work? *

Yes No

Birth Date (01/01/0001) *

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? *

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

Lung Health *

asthma emphysema tuberculosis (tb)

Blood Health *

stroke excessive bleeding leukemia

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? *

Please list additional health problems *

Please list any medications you are taking *

Please list any surgeries *

Height *

Weight *

Females: Are you pregnant? *

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

YOUR CART

Health History Form