Health Hx Form DENTAL HISTORYFull Name(Required) First Last Email(Required) Phone(Required)Reason of visit(Required)Date for last dental visit? MM slash DD slash YYYY Date for last dental X-rays? MM slash DD slash YYYY Do you have or have you had any of the following? (Please check all that apply) Bad breath Grinding teeth Sensitivity of cold Bleeding gums Loose teeth or broken fillings Sensitivity of hot Jaw pain / Clicking or popping jaw Orthodontic treatment Sensitivity of sweets Food collection between teeth Sensitivity when biting Sores or growth in your month How often do you floss?How often do you brush?MEDICAL HISTORYPhysician Name(Required)Date for last visit: MM slash DD slash YYYY Have you had any serious illnesses or operations?(Required) Yes No (Women) Are you pregnant?(Required) Yes No DescribeNursing?(Required) Yes No Taking birth control pills?(Required) Yes No Do you have or have you had any of the following? (Please (Please check all that apply) AIDS Circulatory Problems Mitral Valve Prolapse Rheumatic Fever Anemia Congestive Heart Failure Hemophilia Shortness of Breath Arthritis, Rheumatism Cortisone Treatments Stroke Artificial Heart Valves Cough, Persistent Hepatitis / Jaundice Skin Rash Artificial Joints Cough up Blood High Blood Pressure Swelling of Feet or Ankles Asthma Diabetes HIV Positive Thyroid Problems Back Problems Epilepsy / Seizures Kidney Disease Tobacco Habit Blood Disease Fainting Liver Disease Tonsillitis Cancer Headaches / Migraines Nervous Problems Tuberculosis Chemical Dependency Headaches / Migraines Pacemaker Venereal Disease Chemotherapy Heart Murmur Psychiatric Care Cholesterol Heart Problems Radiation Treatment Respiratory Disease Is there any health information which was not asked, which you feel may influence your dental treatment?MEDICAL HISTORYALLERGIESIs there any health information which was not asked, which you feel may influence your dental treatment?allergies Asprin Barbiturates (sleeping pills) Codeine Latex Local Anaesthetics Penicillin/ Amoxicillin Sulfa Other SIGNATUREThe above information is accurate and complete to the best of my knowledge. I will not hold my dentist or any member of his / her staff responsible for any errors omissions that I may have made in the completion of this form. Date for last dental visit? MM slash DD slash YYYY Signature(Required)