Skip to content
Pricing
Patient forms
About
Frequently Asked Questions
Wisdom Teeth Information
Blog
Contact Us
Menu
Pricing
Patient forms
About
Frequently Asked Questions
Wisdom Teeth Information
Blog
Contact Us
New Patient Health History
Health History
Today’s date
Patient Information
Name
*
Age
*
Date of Birth
*
SSN
use format: xxx-xx-xxxx
Gender
*
Male
Female
Email
*
Home Phone
*
Alt#
Address
*
City
*
State
*
Zip
*
How did you hear about our office?
*
Internet
Friend/Family
Valpak
Billboard
Mailer
Dentist Referred
Other
Other
Who is your Dentist?
Responsible Party
Name of Person Responsible for the Account
*
Responsible Party
*
Self
Parent
Guardian
Group Home & Caretaker
Responsible Party Home Phone
*
Responsible Party Alt#
Medical History
Please Describe the Patient’s current health
*
Excellent
Good
Poor
Height (ft)
3'
4'
5'
6'
7'
Height (in)
0"
1"
2"
3"
4"
5"
6"
7"
8"
9"
10"
11"
Weight (lbs)
*
Has the patient had any food or water in the last 8hrs?
*
Yes
No
Does the patient have history of drugs abuse?
*
Yes
No
Has the patient ever had any of the following medical problems?
Diabetes
Family Hx of Problems w/Anesthesia
Joint Replacements
Cancer
Asthma/Lung Problems/COPD/Sleep Apnea
Any Hospital Stays
Tuberculosis
Heart Defects/Heart Murmurs/ Surgery
Any Operations
Cerebral Palsy
Kidney Disease/Failure/Problems
Endocrine Disease
Currently Pregnant
Rheumatic/Scarlet Fever
Bleeding Problems
Latex Allergy
Autism/Down Syndrome
Seizures or Epilepsy
Anxiety
Developmentally Delayed
Allergies to any Medications
*
Y
N
(please list)
Please discuss any medical problems the patient has/had:
0
of 177 max characters
Is the Patient currently under the care of a physician?
*
Y
N
Date of last visit
*
Physician’s name
*
Office Phone Number
*
Please list all medications the patient is currently taking:
MEDICATION
DOSE
Directions
plus1
Add
minus1
Remove
Section
If you are human, leave this field blank.
Submit
Great News!
You're eligible, but with different insurance plans the cost will vary between providers
We estimate pricing to be around $50-$600
Contact Us Today
