Health History — Eastgate Family Dental

Eastgate Family Dental

Grand Rapids, Michigan

2003 Burton St SE · Grand Rapids, MI 49506
Phone: (616) 245-9830 · Fax: (616) 245-5026
www.eastgatefamilydental.com

Dental & Health History

Patient Information

Patient Name

Date of Birth

Today's Date

Physician's Name

Dental History

Former Dentist / Practice

City / State

Date of Last Visit

Date of Last X-Rays

Reason for Today's Visit

How often do you brush? / How often do you floss?

Do you have any concerns about your teeth or smile? (pain, appearance, function, sensitivity, etc.)

Have you had or do you currently experience any of the following? (check yes or no)

Medical History

Date of Last Physical Exam

Results / Notes

Do you have or have you ever had any of the following conditions?

Medications & Allergies

Current Medications (list all, including over-the-counter)

Pharmacy Name

Pharmacy Phone

Do you have allergies to any of the following?

Bisphosphonate Medication History

Have you ever taken a bisphosphonate medication? (e.g., Fosamax, Prolia, Boniva, Reclast, Actonel) Yes No

Medication Name(s)

Last Date Taken

How Long Taken (e.g., 2 years)

For Women

Authorization

To the best of my knowledge, all of the above information is complete and correct. I understand that it is my responsibility to inform this office of any changes in my health status. I authorize the dental staff to perform the necessary dental services I may need.

Signature of Patient or Guardian

Date

Updates — To Be Completed at Future Appointments

Has there been any change in your health since your last dental appointment?

Yes No

If yes, describe

Any new medications?

Patient Signature

Date

Doctor Signature

Date