LakeView Family Dental Logo
26206 W 12 Mile Rd Southfield, MI 48034 (248) 356-8790

Simply complete the form below and someone from our dental team will contact you soon.

Health History Form

Montgomery Plaza Dental

The benefits of a happy, healthy smile are immeasurable! Our goal is to help you reach and maintain maximum
oral health. Please fill out this form completely. The better we communicate, the better we can care for you.


About You

  • Today's Date
  • E-mail Address
  • Full Name (Last, First, Initial)
  • , ,
  • Mr. Mrs. Ms. Dr.
  • I prefer to be called
  • Responsible Party Name (Last, First, Initial)
  • , ,
  • Date of Birth
  • Social Security
  • Marital Status
  • Single Married Widowed Separated Divorced
  • Home Adress
  • City, State Zip
  • ,
  • Phone
  • Home- Work- Cell-
  • Driver's License
  • Whom may we thank for referring you?
  • Other family members seen by us
  • Employer
  • How long there?
  • Occupation
  • Employer's Address
  • City, State Zip
  • ,

Emergency Information

  • His/Her Name
  • Relation
  • Phone
  • Home-
  • Work-
  • Address
  • City, State Zip
  • ,

Spouse Information

  • His/Her Name
  • Relation
  • Social Security
  • Date of Birth
  • Employer
  • Driver's License
  • Phone
  • Home-
  • Work-

Dental Insurance Information

Primary Insurance

  • Insurance Co. Name
  • Phone
  • Group #
  • Insurance Co. Address
  • Insured's Name
  • Insured's Social Security #
  • Insured's Birthdate
  • Insured's Employer
  • Employer's Address
  • City, State Zip
  • ,

Medical History

  • Do you have a personal physician?
  • Yes No
  • Physician's Name
  • Phone
  • Date of last visit
  • Your current physical health is
  • Fair Good Poor
  • Are you currently under the care of a physician?
  • Yes No
  • Please explain
  • Are you taking any prescription/over-the-counter drugs?
  • Yes No
  • Please list each one
  • For Women Are you taking birth control pills?
  • Yes No
  • Are you pregnant?
  • Yes No
  • When due:
  • NOTE: Oral antibiotics may interfere with the effectiveness of oral contraceptives. Please consult with your physician.
  • Please check any of the following diseases or medical problems you have ever had.
  • Abnormal Bleeding Alchol / Drug Abuse
    Anemia Arthitis
    Artificial/Joints/Valves Asthma
    Blood Transfusion Cancer/Chemotherapy
    Chest Pain Congenital Heart Defect
    Diabetes Difficulty Breathing
    Epilepsy Excessive Bleeding
    Fainting Spells Frequent Headaches
    Glaucoma HIV / AIDS
    Hay Fever Heart Attack/Surgery
    Heart Murmur Hemophilia
    Hepatitis, Any Form Herpes / Fever Blisters
    High Blood Pressure Hospitalized for Any Reason
    Kidney Problems Liver Disease
    Low Blood Pressure Mitral Valve Prolapse
    Pacemaker Psychiatric Problems
    Radiation Treatment Rheumatic / Scarlet Fever
    Seizures Sickle Cell Disease / Traits
    Sinus Problems Stroke
    Thyroid Problems Tuberculosis (TB)
    Ulcers Venereal Disease
  • Please list any serious medical condition(s) that you have ever had
  • I have no prior or existing medical conditions.
  • True False
  • Are you allergic to any of the following?
  • Aspirin Codeine Dental Anesthetics
    Erythromycin Jewelry/Metals Latex
    Penicillin Tetracycline Other
  • Please list any other drugs/materials that you are allergic to
  • I have no drug or material allergies.
  • True False

Dental History

  • Why have you come to the dentist today?
  • Are you currently in pain?
  • Yes No
  • Do you require antibiotics before dental treatment?
  • Yes No
  • Previous dentist
  • Last visit
  • Last cleaning date
  • Last x-ray date
  • Why did you leave your previous dentist?
  • What did you like most & least about any dentist you have seen?
  • Your Current dental health is
  • Fair Good Poor
  • Have you ever had a serious/difficult problem associated with any previous dental work?
  • Yes No

  • How often do you brush?
  • times per day
  • How often do you floss?
  • times per day
  • Do you smoke or use tobacco in any other form?
  • Yes No
  • Are your teeth sensitive to heat, cold or anything else?
  • Do you have loosening of teeth?
  • Yes No
  • Do you still have wisdom teeth?
  • Yes No
  • Do your gums ever bleed?
  • Yes No
  • Have you ever had periodontal disease?
  • Yes No
  • Have you ever had gum treatments?
  • Yes No
  • Does food catch between your teeth?
  • Yes No
  • Do you now or have you ever experienced pain / discomfort in your jaw joint (TMJ / TMD)?
  • Yes No
  • Do you clench or grind your teeth?
  • Yes No
  • Do you have clicking or popping of your jaws?
  • Yes No
  • Would you like fresher breath
  • Yes No
  • Whiter teeth?
  • Yes No
  • Are you happy with the way your smile looks?
  • Yes No
  • If not what whould you change
  • Have you ever tride Nitrous Oxide (relaxing gas)?
  • Yes No
I affirm that the information I have given is correct to the best of my knowledge. It will be held in the strictest confidence and will only be used as stated in this office's Privacy Policy. My signature will serve as my written authorization until I choose to revoke it, in writing. It is my responsibility to inform this office of any changes in my medical status. I authorize the dental staff to perform the necessary dental services I may need. Responsibility for payment for Dental Services provided in this office is that of the patient or responsible party, due and payable at the time services are rendered. I certify that if I am covered by dental insurance, I assign directly to Dr. John S. Rubin all insurance benefits otherwise payable to me. I also understand that if after two months (60 days) my insurance company has not paid the claim or if there is an outstanding balance still due after insurance, then it becomes my responsibility. I authorize the use of my signature on all my insurance submissions to secure the payment of benefits. A 1.50% finance charge (18% annually) will be added to any balance over 60 days due.
  • Enter your name to agree to our Privacy Policy
  • Enter your name to agree to our Payment Policy

Office Hours:

  • Monday: 8:00am to 5:00pm
  • Tuesday: 8:00am to 5:00pm
  • Wednesday: 8:00am to 5:00pm
  • Thursday: 8:00am to 5:00pm

(248) 356-8790