Health History Form

Legal Name prefix
Gender
Marital Status
Have you been seen before?
Self Please skip this section and continue below
Marital status 2
accident related
work related
health changes past year
under physicians care
ever been hospitalized
cardiovascular disease
Asthma Lung disease
Asthma Lung disease_1
Emphysema
lungs
Heart Attack
Heart Murmur
Coronary Artery Disease
COPD
Shortness of Breath
Chest Pain
High Blood Pressure
Stroke
Chest Pain_1
Severe Coughing
A fib
Heart Surgery
Pacemaker
Neurologic psychologic disorder
psychologic disorder
High Cholesterol
Anxiety
Depression
Seizures
implants
ADHD
Parkinson s
Heart Valve
Hip
Knee
Other
Kidney Failure Kidney disease
Kidney Failure Kidney disease_1
Dialysis
kidneys
Bleeding Disorder
Anemia
Bleeding Tendency
thyroid
Blood Transfusion
Bruise Easily
blood
Hyperthyroid
Hypothyroid
Hepatitis A
Hepatitis A_1
B
C Liver disease
liver
diabetes
Type I
Type II
Stomach ulcers
Colitis
Reflux GERD
stomach
arthritis
Osteoporosis
Osteopenia
osteoporosis
Rheumatoid
Osteoarthritis
sleep
Sinus Problems
Nasal Problems
nasal
Sleep Apnea
NO
headaches
Headache
Migraines
Head Injury
Cancer
Chemotherapy
Radiation head neck
cancer
tmj
Clicking
Popping
PainWithin the Jaw Joint
Difficulty OpeningMouth
other diseases
family diabetes
family cancer
family heart disease
family bleeding
are you pregnant?
birth control
NO
allergies
smoke ciggarettes
vape
previously smoked
drug abuse
emotional disorders
alcoholism
alcohol
recreational drugs
effects from dental work
talk privately
do you have insurance
di marital status
mi marital status
di gender
mi gender
di relationship
mi relationship
di martital status 2
mi marital status 2
di gender 2
mi gender 2
di relationship 2
mi relationship 2
Cash
Check
Visa
Mastercard
Amex
Discover
Spouse
Parent s
Child
Other
NO
Home Number
Cell Number
ok to leave message
x

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