Confidential Health History Form
Please fill out this form to the best of your ability.  If you are unsure about any questions, please leave them blank.  For questions or concerns, contact us immediately.  (530)621-0900
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Patient Name *
Email *
Phone *
Gender
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Marital status
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Yes
No
Unsure
Is your general health good?
Has there been a change in your health within the last year?
Have you gone to the hospital or emergency room or had a serious illness in the last three years?
Are you being treated by a physician now? If
Have you had problems with prior dental treatment?
Are you in pain now?
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Please check if you have ever experienced any of the following.
PLEASE CHECK IF YOU HAVE OR EVER HAD ANY OF THE FOLLOWING?
ARE YOU ALLERGIC TO OR HAVE YOU HAD A REACTION TO ANY OF THE FOLLOWING
ARE YOU TAKING OR HAVE YOU TAKEN ANY OF THE FOLLOWING IN THE LAST THREE MONTHS
WOMEN ONLY
All Patients (Continued)
Do you have or have you had any other diseases or medical problems NOT listed on this form?
Have you ever been pre-medicated for dental treatment?
HAVE YOU TAKEN (OR CURRENTLY TAKING) ANY OF THE FOLLOWING MEDICATIONS?
Is there any issue or condition that you would like to discuss with the dentist in private?
The practice of dentistry involves treating the whole person. If the dentist determines that there may be a potentially medically compromised situation, medical consultation may be needed prior to commencement of dental treatment.
I authorize the dentist to contact my physician.
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Whom would you like us to contact in case of an emergency? (Name, Relationship, Phone Number)
I certify that I have read and understand this form. To the best of my knowledge, I have answered every question completely and accurately. I will inform my dentist of any change in my health and/or medication. Further, I will not hold my dentist, or any other member of his/her staff, responsible for any errors or omissions that I may have made in the completion of this form. *
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