Before your first visit
Your health history, one step at a time
Complete a section, then move to the next. You can go back and change any answer before saving your form.
Your answers stay on this page and are not sent to the office. Save your completed PDF before closing or refreshing the page.
Step 1 of 7
About you
Start with your contact details. Required questions are marked. Other details can be discussed at your visit.
Medical history
Have you ever been diagnosed with any of these conditions? Choose Yes, No, or Not sure for each. The dental team can help clarify your answers.
Explain Yes or Not sure answers, other conditions, current care, and recent surgery or hospital stays. Include dates if known.
Medicines
Include prescriptions, over-the-counter medicines, vitamins, and supplements. Remember diabetes or weight-loss medicines (including GLP-1 medicines), blood thinners, steroids, and pain medicines.
Need more than six medicines? List the rest here with the dose, how often, and reason if known.
Allergies & reactions
Include allergies to medicines, latex, adhesives, metals, and foods. Then answer three questions about past treatment or medicines.
If Yes or Not sure: give medicine names and dates, the condition, or the reaction, if known.
Dental concerns
Tell us what matters to you and what you would like help with. Check any current concerns that apply.
Include deep cleaning, gum surgery, implants, and dental complications, with dates if known.
Health & comfort
These details help the team prepare for your visit. You can write “Discuss privately” in the text boxes if you prefer to speak with the team.
Type, amount, and frequency. Write None if applicable, or Discuss privately.
Review & finish
Check your answers below. Use Edit to make changes. Blank optional questions are shown as “Not provided.”
I will tell the dental team about changes to my health or medicines. This health history is not consent to treatment.
Open the PDF and use its Print button, or save a copy to your device. Longer answers appear on additional pages.
How do I send or email my completed form?
Download your PDF, then email it to drsmith@johnsmithdds.com before your visit, or bring a printed copy. This page does not send the form.
- Chantilly, Virginia: (703) 488-9921
- Washington, DC: (202) 347-0100