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Health History Questionnaire
Name:
*
Phone Number:
*
Email:
*
Date of Birth:
*
month
January
February
March
April
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June
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October
November
December
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Specific Treatment:
Any heart disease:
*
yes
no
Hipertension max.:
Hipertension min.:
Diabetes:
*
yes
no
Colesterol:
*
yes
no
Hyperglucemia:
*
yes
no
Uric acid:
*
yes
no
Hepatitis A, B, C:
*
yes
no
HIV Virus or AIDS:
*
yes
no
Any other transmisible disease:
*
yes
no
If yes, please give details:
Have you ever been surgically intervented?:
*
yes
no
If yes, please give details:
Have you ever received a blood transfusion?:
*
yes
no
If yes, please give details:
Have you visited a doctor the last 6 months?:
*
yes
no
If yes, please give details:
Are you pregnant?:
*
yes
no
Do you smoke?:
*
yes
no
If yes, how many cigarettes a day?:
yes
no
Do you drink alcolhol regularly?:
*
yes
no
Do you take any drug?:
*
yes
no
Any allergies?:
*
yes
no
Are you allergic to any medicine?:
*
yes
no
Have you had any tooth extracted?:
*
yes
no
Have you had continuous bleeding alter a tooth extraction?:
*
yes
no
Do your gums bleed while brushing?:
*
yes
no
Have you observed mobility on your teeth?:
*
yes
no
Is something not feeling well in your mouth?:
*
yes
no
If yes, please give details:
Have you had any accident that might affect your mouth or teeth?:
*
yes
no
Do you have any digestive problem?:
*
yes
no
Do you swallow food without having chewed enough?:
*
yes
no
Do you clench your teeth?:
*
yes
no
If so, during the day or night?:
Have you noticed if your teeth look shorter?:
*
yes
no
Have you ever been diagnosed with gyngivitis o periodontal disease (pyorrea)?:
*
yes
no
Do you wear any fixed prosthesis?:
*
yes
no
If so, how old (years)?:
Do you wear any removible prosthesis?:
*
yes
no
If so, how old (years)?:
Have you ever learned how to brush teeth?:
*
yes
no
How many times a day do you brush your teeth?:
*
When was your last visit to the dentist?:
*
Date of your last hygiene?:
*
month
January
February
March
April
May
June
July
August
September
October
November
December
day
1
2
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5
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Date of your last blood analysis?:
*
month
January
February
March
April
May
June
July
August
September
October
November
December
day
1
2
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Is there any aesthetic factor that bothers you?:
Other comments:
