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Health History

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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

Medications
Do you take, or have you used, Phen-fen or Redux?*
- Yes
- No
Do you take bone density medications?
Actonel*
- Yes
- No
Aredia*
- Yes
- No
Atelvia*
- Yes
- No
Boniva*
- Yes
- No
Binosto*
- Yes
- No
Didronel*
- Yes
- No
Donefoe*
- Yes
- No
Fosamax*
- Yes
- No
Redast*
- Yes
- No
Skelid*
- Yes
- No
Zometa*
- Yes
- No
If other bone density medications, please list
Are you taking any blood thinners?
Asprin*
- Yes
- No
Coumadin/Warfarin*
- Yes
- No
Eliquis*
- Yes
- No
Heparin*
- Yes
- No
Pradaxa*
- Yes
- No
Xarelto*
- Yes
- No
If other blood thinner, please list
Are you allergic to:
Penicillin*
- Yes
- No
Clindamycin*
- Yes
- No
Metal Sensitivity*
- Yes
- No
Latex*
- Yes
- No
Tetracycline*
- Yes
- No
If other allergy medications, please list
Are you taking any medications?*
- Yes
- No
If others, please list
Do you use Tobacco?*
- Yes
- No
If yes, How long? How much and what type?
Do you use controlled substances?*
- Yes
- No
If yes, what substances?
Women: Are you..
- Pregnant/Trying to get pregnant
- Nursing
- Taking oral contraceptives
Do you have, or have you had, any of the following?
AIDS/HIV Positive*
- Yes
- No
Alzheimer's Disease*
- Yes
- No
Anemia*
- Yes
- No
Artifical Heart Valve*
- Yes
- No
Asthma*
- Yes
- No
Stroke*
- Yes
- No
Mitral Valve Prolapse*
- Yes
- No
Tuberculosis*
- Yes
- No
Congenital Heart Disorder*
- Yes
- No
Steroid Medicine*
- Yes
- No
Diabetes*
- Yes
- No
Herpes*
- Yes
- No
Excessive Bleeding*
- Yes
- No
Fainting Spells/Dizziness*
- Yes
- No
Bruise Easily*
- Yes
- No
Chest Pains*
- Yes
- No
Cold Sores/Fever Blisters*
- Yes
- No
Ulcers*
- Yes
- No
Hemophilia*
- Yes
- No
Drug/Alcohol Additions*
- Yes
- No
High Blood Pressure*
- Yes
- No
Artificial Joint*
- Yes
- No
Sinus Trouble*
- Yes
- No
Cancer*
- Yes
- No
Heart Attack/Failure*
- Yes
- No
Heart Murmur*
- Yes
- No
Heart Trouble/Disease*
- Yes
- No
Radiation Treatments*
- Yes
- No
Hepatitis B or C*
- Yes
- No
Epilepsy or Seizures*
- Yes
- No
Hypoglycemia*
- Yes
- No
Breathing Problems*
- Yes
- No
Chemotherapy*
- Yes
- No
Osteoporosis*
- Yes
- No
Pain in Jaw Joints*
- Yes
- No
Psychiatric Care*
- Yes
- No
Do you have any physical or medical conditions not listed above?
If yes, please list

Dental History
Do you have specific problems?*
- Yes
- No
If yes, please describe
Has fear of discomfort kept you from dental visits?*
- Yes
- No
Do your gums bleed?*
- Yes
- No
Do you clench or grind your teeth?*
- Yes
- No
Have you ever had the following
Injury to face, jaws or teeth*
- Yes
- No
Orthodontics*
- Yes
- No
Oral Surgery*
- Yes
- No
Periodontal (gum) Treatment*
- Yes
- No
Do you take fluoride supplements?(children)
- Yes
- No
Do you have a Medical Power of Attorney?*
- Yes
- No
If yes, who?
Consent
I agree to this Health History.
To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in my medical status.

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We will do our best to accommodate your busy schedule. Schedule an appointment today! Call us today 231-929-3606

Testimonials

"Professional, caring dentist. I highly recommend Deerhaven Dentistry – I have referred many people to them. They are professional, knowledgeable, experienced and they stay up with new technology while creating a warm, caring, personal environment. They make an annual trip to an under-developed country each year to help people in 3rd world countries with dental hygiene. They have a customer for life! " - Debi P.

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Contact Us

Deerhaven Family Dentistry
5217 North Royal Drive
Traverse City, MI 49684
231.929.3606

Red Hot Best 2018

Location

Office Hours

Mon

8:00 a.m. - 5:00 p.m.

Tue

8:00 a.m. - 5:00 p.m.

Wed

8:00 a.m. - 5:00 p.m.

Thu

8:00 a.m. - 5:00 p.m.

Fri

7:00 a.m. - 1:00 p.m.

Sat

Closed

Sun

Closed

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