Name * First Name Last Name Email * Phone Number: * Country (###) ### #### Address Address 1 Address 2 City State/Province Zip/Postal Code Country Sex: * Male Female Date of Birth: * MM/DD/YYYY Emergency Contact Information: * First Name Last Name Phone * Country (###) ### #### Insurance Information Insurance Provider Subscriber Name First Name Last Name Relation to Patient Birthdate of Subscriber mm/dd/yyyy SSN/Member ID Group # Is patient covered by additional insurance? Yes No Dental History Former Dentist * City/State of former dentist * Date of last dental visit * Email of previous dentist * Do you have any concerns for Dr. Pitt or your hygienist in regards to your oral health? Yes No Health History Name of Primary Care Physician Phone of Primary Care Physician Office: Country (###) ### #### Aids/HIV Yes No Anemia Yes No Arthritis/Rheumatism Yes No Artificial Heart Valves Yes No Artificial Joints Yes No Autism Spectrum Disorder Yes No Back Problems Yes No Cancer Yes No Chemical Dependency/Substance Abuse Yes No Congenital Heart Defects Yes No Persistent Cough Yes No Diabetes Yes No Pre-Diabetes Yes No Emphysema/COPD Yes No Epilepsy Yes No Fainting or Dizziness Includes Vertigo Yes No Headaches/Migraines Yes No Heart Attack Yes No Heart Problems Yes No Hepatitis Yes No Herpes Virus Yes No High Blood Pressure Yes No Kidney Disease Yes No Liver Disease Yes No Low Blood Pressure Yes No Nervous System Problems Yes No Pacemaker Yes No Psychiatric Care Yes No Shortness of Breath Yes No Sinus Trouble Yes No Special Needs Yes No Stroke Yes No Thyroid Problems Yes No Tuberculosis Yes No Tumor/growth on head or neck Yes No Have you taken any of the following medications within the past 6 months? None Blood Thinners Insulin, Orinase, or something similar Aspirin Digitalis Nitroglycerin Bisphosphonates Semaglutides (ex: Ozempic) Tirzepatides (ex: Mounjaro) Do you have allergies to any of the following? Please check all that apply No Known Drug Allergies NSAIDS Acetaminophen (Tylenol) Codeine Iodine Latex Local Anesthetic Penicillin/Amoxicillin Antibiotics Metals Sulfa Drugs Please list any medications you are currently taking: Preferred Pharmacy Name Preferred Pharmacy Address Address 1 Address 2 City State/Province Zip/Postal Code Country Women Are you currently pregnant? Yes No Are you currently nursing? Yes No Have you reached menopause? Yes No Digital Signature: * Please type your name to verify that this information is accurate and up to date. I understand that any false, misleading, or missing information on this form can result in incorrect diagnosis/treatment planning and/or dismissal from the practice. Thank you for submitting your Health History Form. This will allow your next appointment to begin quickly and move smoothly. Health History Form
