Fill Out Form Patient Health History Update

206-487-7800 • 1515 N. 200TH ST., SHORELINE, WA 98133

Name Fields marked with * are required

First Name *

Last Name *

Home Address *

Apt. or Ste. (optional)

City *

State

Zip *

Home Phone *

Cell Phone

Emergency Phone

Health History Fields marked with * are required

Fever over 100.4F * Yes No

Headache * Yes No

Sore Throat * Yes No

Dry Cough * Yes No

Chills * Yes No

Shortness of breath * Yes No

Difficulty breathing * Yes No

Loss of taste or smell * Yes No

Are you in contact with any confirmed COVID-19 positive patients? * Yes No

Have you traveled to any regions affected by COVID-19 in the past 14 days? * Yes No

Have you ever had a serious/difficult problem associated with any previous dental work? * Yes No

If Yes Please Explain:

Are you currently being treated by a physician? * Yes No

If Yes Please Describe:

Have you ever been hospitalized or had a major operation? * Yes No

If Yes Please Describe:

Have you ever had a serious face, mouth, teeth, or chin injury? * Yes No

If Yes Please Describe:

Do you smoke cigarettes or cigars? * Yes No

Do you Vape? * Yes No

Do you drink alcohol? * Yes No

If yes, How Much/How Often:

Women: Are you pregnant / Trying to get pregnant? * Yes No

Nursing? * Yes No

Taking oral contraceptives? * Yes No

have you ever been evaluated for orthodontic treatment? * Yes No

have you ever had a serious / difficult problem associated with any previous dental work? * Yes No

Do you now or have you ever experience pain / discomfort in your jaw joint (TMJ/TMDJ)? * Yes No

DO YOUR GUMS EVER BLEED? * Yes No

Do you like your smile? * Yes No

If no, Why?

Do you know if you snore? * Yes No

Do you wear a night guard? * Yes No

Do you have any missing or extra permanent teeth? * Yes No

Are you anxious/nervous about dental treatment? * Yes No

Clicking/popping jaw/jaw pain or tiredness? * Yes No

Does food catch between your teeth? * Yes No

Do you have sensitivity to hot/cold foods or liquids? * Yes No

Do you have slow healing sores in your mouth? * Yes No

Does your jaw get stuck so you can't open easily? * Yes No

Chew on one side of your mouth? * Yes No

Lip or cheek biting? * Yes No

History of periodontal problems * Yes No

Do you gag easily? * Yes No

Do you wear dentures? * Yes No

Do you clench or grind? * Yes No

Do you have sensitivity to sours? * Yes No

Do you have sensitivity to sweets? * Yes No

Do you have loose teeth? * Yes No

Do you have broken fillings? * Yes No

Medications Fields marked with * are required

Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates? * Yes No

If Yes, when did you take the medication and for how long?

Please List Prescriptive Medications and what they're being taken for

Please list over the counter medications and what they're being taken for

Are You Allergic To Any Of The Following Fields marked with * are required

Aspirin, Acetaminophen, or ibuprofen * Yes No

Penicillin * Yes No

Codeine, Demerol, or other Narcotics * Yes No

Acrylic * Yes No

Metal * Yes No

Latex or Rubber Dam * Yes No

Tetracycline * Yes No

Erythromycin * Yes No

BARBITURATES, SEDATIVES, OR SLEEPING PILLS * Yes No

Sulfa Drugs * Yes No

Any Local Anesthetics * Yes No

Do you use controlled substances? * Yes No

If Yes:

Please list any other drug/materials that you are allergic to:

Do You Have, Or Have You Had, Any Of The Following Fields marked with * are required

ADHD

AIDS/HIV Positive

Alzheimer's Disease

Anaphylaxis

Anemia

Angina

Arthritis/Gout

Artificial Heart Valve

Artificial Joint

Asthma

Blood Disease

Blood Transfusion

Breathing Problems

Bruise Easily

Cancer

Chemotherapy

Chest Pains

Cold Sores / Fever Blisters

Congenital Heart Disorder

Convulsions

Yellow Jaundice

Cortisone Medicine

Diabetes

Drug Addiction

Easily Winded

Emphysema

Epilepsy or Seizures

Excessive Bleeding

Excessive Thirst

Fainting Spells / Dizziness

Frequent Diarrhea

Frequent Headaches

Glaucoma

HayFever

Heart Attack / Failure

Heart Murmur

Heart Pacemaker

Heart Trouble / Disease

Sleep Apnea

Hemophilia

Hepatitis A

Hepatitis B or C

Herpes

High Blood Pressure

High Cholesterol

Hives or Rash

Hypoglycemia

Irregular Heartbeat

Kidney Problems

Leukemia

Liver Disease

Low Blood Pressure

Lung Disease

Mitral Valve Prolapse

Osteoporosis

Pain In Jaw Joints

Parathyroid Disease

Psychiatric Care

Snoring

Radiation Treatments

Recent Weight Loss

Renal Dialysis

Rheumatic Fever

Rheumatism

Scarlet Fever

Shingles

Sickle Cell Disease

Sinus Trouble

Stomach / Intestinal Disease

Stroke

Swelling Of Limbs

Thyroid Disease

Tonsillitis

Tuberculosis

Tumors or Growths

Ulcers

Venereal Disease

Have you ever had any serious illness not listed? * Yes No

If Yes:

Comments

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Date: 5/11/2024

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