HEALTH HISTORY QUESTIONNAIRE Date - Dr Joe Dentistry 2026

1. Click ‘Get Form’ to open the HEALTH HISTORY QUESTIONNAIRE in the editor.
2. Begin by entering the date at the top of the form, followed by your full name, including first, middle initial, and last name.
3. Fill in your address details, including street, apartment/unit number, city, state, and zip code. Select your gender by checking the appropriate box.
4. Provide your social security number, cell phone number, home phone number, email address, employer's name, occupation, and birthdate.
5. Rate your smile on a scale from 1 to 10 and indicate your level of dental anxiety using the provided scale.
6. Complete the dental insurance section by filling in details about the person responsible for the account and their relationship to you.
7. Answer all medical health questions honestly by checking 'Yes' or 'No' as applicable. Provide additional information where prompted.
8. List any medications you are currently taking along with their dosages and frequency of use.
9. For women only: Indicate if you are pregnant or nursing and provide relevant details.
10. Review all entered information for accuracy before signing and dating the authorization section at the end of the form.

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