Health History

Patient Name*
First Last
Birth Date*
MM
DD
YYYY
Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you have, or medication that you may be taking,
Emergency Contact Name/Phone
Emergency Contact Name*
Emergency Phone Number*
Who is your primary physician? and Phone Number
Physician Name*
Physician Phone*
Who is your previous dentist?*
Whom may we thank for referring you?*
Date of last physical exam?
Date Format: MM slash DD slash YYYY
Have you been hospitalized in the past five years? If yes, why?*
- Yes
- No
Hospitalized in the past five years

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