Health History Form - DS Family and Cosmetic Dentistry

Patient Name

PrefixFirst NameMiddle NameLast Name

Preferred Name

Check all of the following that you may have had in the past or that currently apply to you:

*If you've selected Cancer, Diabetes (A1C), Heart Attack, or Other, please provide more details:

Are you allergic to or have you reacted adversely to any of the following medications? Please check all that apply.

Other:

Have you ever taken any of the following medications? Please check all that apply, and provide start/end dates.

Are you currently taking any medications? If yes, please list:

Do you need antibiotics prior to receiving dental care? If so, which type/dosage?

Do you take Coumadin or Plavix or any other blood thinner? If yes, do you know your typical INR?

Please describe your present health

When was your last visit with your primary care physician?

Are you currently under a physician’s care? If yes, please list reason:

Has there been any change in your general health in the past year? If yes, please explain:

Please list any other serious illness, hospitalization, or condition in the last 5 years if not listed above:

Are you a past or present smoker/vaper?

If yes, how many cigarettes/cigars/mg per day?

Do you have any history of substance abuse, or do you currently use recreational drugs?

The above information on this form has been accurately answered and is true to the best of my knowledge. I understand that providing incorrect information can be dangerous to my or the patient’s health. I understand that it is my responsibility to inform Dr. Daniel C. Sluyk, DDS of any changes in my or the patient’s medical status.

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