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Health History Form – Behavioral Health

Patient Name(Required)
Sex(Required)
MM slash DD slash YYYY
Are your immunizations up to date?(Required)
Are you now under the care of a physician?(Required)
Are you presently taking any medications/drugs/pills that include over-the-counter medications and dietary supplements?(Required)
If yes, list all medications/drugs/pills including over-the-counter medications and dietary supplements.
Medication name
How much
How often
 
Have you ever received a colorectal cancer screening(colonoscopy or stool test)?(Required)
Are you sensitive or allergic to latex? (i.e. experienced itching, rash or wheezing after using latex gloves or handling a balloon)(Required)
Are you allergic or have an adverse reaction to:(Required)
Do you have ANY allergies? This includes food, environmental, etc.(Required)
Please list any known allergies and their reaction:
Medication, food, environmental etc:
Reaction-symptoms (rash, swelling, etc):
Severity(mild, moderate or severe)
 
Have you ever had any unusual reactions during a surgical procedure?(Required)
Have you had any other serious illness, hospitalization or accident?(Required)

Do you currently have, or have had any of the following:

(Yes or No)
(Yes or No)
(Yes or No)
Have you used tobacco(Required)
Have you used tobacco products in the last 30 days?(Required)
Do you currently use the following non-smoking tobacco products
Do you currently use the following tobacco products?
Do you drink alcoholic beverages?(Required)
If yes, types of Alcohol:
Frequency:
Amount:
Last drink:
Do you drink/consume caffeine?(Required)
Types of caffeine:
Caffeine per day:
Do you use marijuana(Required)
Do you use other substances?(Required)

Dental History

MM slash DD slash YYYY
Do you have any sores or lumps in or near your mouth?(Required)
Do your gums bleed while brushing or flossing?(Required)
Are your teeth sensitive to hot or cold liquids/foods?(Required)
Do you have frequent headaches?(Required)
Do you clench or grind your teeth?(Required)
Have you ever had any orthodontic work?(Required)
Are your teeth sensitive to sweet or sour liquids/foods?(Required)
Have you ever had prolonged bleeding following extractions?(Required)
Do you feel pain to any of your teeth?(Required)
Have you ever had instruction on the correct method of brushing your teeth?(Required)
Have you ever had any head, neck or jaw injuries?(Required)
Have you experienced any of the following:
MM slash DD slash YYYY

Patient or Patient Guardian signature:

Name(Required)
MM slash DD slash YYYY