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Dental & Medical History Form

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Dental & Medical History Form

Please Read and Complete the Form Below

"*" indicates required fields

Patient Information

Date:*

MM slash DD slash YYYY

SS / HIC / ID #:

Last Name:*

First Name:*

Middle Initial:

Address:*

Email:*

City:*

State:*

Zip:*

Sex:*

Male

Female

Age:*

Birthdate:*

MM slash DD slash YYYY

Marital Status:*

Married

Widowed

Single

Minor

Separated

Divorced

Partnered For (how many years?)

If Partnered, How Many Years?*

Patient Employer / School

Occupation:

Employer / School Address:

Employer / School Phone:

Spouse's Name:

Birthdate:

MM slash DD slash YYYY

SS #:

Spouse's Employer:

Whom May We Thank for Referring You?

Dental Insurance

Who is responsible for this account?

Relationship to Patient:

Insurance Co.:

Group #:

Is Patient Covered By Additional Insurance?

Yes

No

Subscriber's Name:

Birthdate:

MM slash DD slash YYYY

SS #:

Relationship to Patient:

Insurance Co.:

Group #:

ASSIGNMENT AND RELEASE

I certify that I, and/or my dependent(s), have insurance coverage with

Name of Insurance Company(ies)

and assign directly to Dr.

Name of Doctor

all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions. The above-named dentist may use my health care information and may disclose such information to the above-named insurance Company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. This consent will end when my current treatment plan is completed or one year from the date signed below.

Signature of Patient, Parent, Guardian or Personal Representative

Please Print Name of Patient, Parent, Guardian or Personal Representative:

Date:

MM slash DD slash YYYY

Relationship to Patient:

Phone Numbers

Home:*

Or Primary (cell, etc.)

Work:

Ext:

Alt. Phone:

Spouse's Work

Best Time and Place to Reach You:*

IN CASE OF EMERGENCY, CONTACT (Specify someone who does not live in your household.)

Name:*

Relationship:*

Phone:*

Alt. Phone:

Dental History

Reason for Today's Visit:*

Former Dentist:

City:

State:

Date of Last Dental Visit:*

MM slash DD slash YYYY

Date of Last Dental X-Rays:*

MM slash DD slash YYYY

Please Select "Yes" or "No" to indicate if you have had any of the following:

Bad Breath:*

Yes

No

Bleeding Gums:*

Yes

No

Blisters on Lips or Mouth:*

Yes

No

Burning Sensation on Tongue:*

Yes

No

Chew On One Side of Mouth:*

Yes

No

Cigarette, Pipe, or Cigar Smoking:*

Yes

No

Clicking or Popping Jaw:*

Yes

No

Dry Mouth:*

Yes

No

Fingernail Biting:*

Yes

No

Food Collection Between the Teeth:*

Yes

No

Foreign Objects:*

Yes

No

Grinding Teeth:*

Yes

No

Gums Swollen or Tender:*

Yes

No

Jaw Pain or Tiredness:*

Yes

No

Lip or Cheek Biting:*

Yes

No

Loose Teeth or Broken Fillings:*

Yes

No

Mouth Breathing:*

Yes

No

Mouth Pain, Brushing:*

Yes

No

Orthodontic Treatment:*

Yes

No

Pain Around Ear:*

Yes

No

Periodontal Treatment:*

Yes

No

Sensitivity to Cold:*

Yes

No

Sensitivity to Heat:*

Yes

No

Sensitivity to Sweets:*

Yes

No

Sensitivity When Biting:*

Yes

No

Sores or Growths in Your Mouth:*

Yes

No

How Often Do You Floss?*

How Often Do You Brush?*

Health History

Physician's Name:*

Date of Last Visit:*

MM slash DD slash YYYY

Have you ever used a bisphosphonate medication? Common brand names are Fosamax, Actonal, Atelvia, Didronal, and Bonia:*

Yes

No

Have you ever taken any of the group of drugs collectively referred to as "fen-phen?" These include combinations of Ionimin, Adipex, Fastin (brand name s of phentermine), Pondimin (fenfluramine), and Redux (dexfenfluramine):*

Yes

No

Please Select "Yes" or "No" to indicate if you have had any of the following:

AIDS / HIV:*

Yes

No

Anemia:*

Yes

No

Arthritis, Rheumatism:*

Yes

No

Artificial Heart Valves:*

Yes

No

Artificial Joints:*

Yes

No

Asthma:*

Yes

No

Back Problems:*

Yes

No

Bleeding Abnormally, With Extractions or Surgery:*

Yes

No

Blood Disease:*

Yes

No

Cancer:*

Yes

No

Chemical Dependency:*

Yes

No

Chemotherapy:*

Yes

No

Circulatory Problems:*

Yes

No

Congenital Heart Lesions:*

Yes

No

Cortisone Treatments:*

Yes

No

Cough, Peristent or Bloody:*

Yes

No

Diabetes:*

Yes

No

Emphysema:*

Yes

No

Do You Wear Contact Lenses:*

Yes

No

Epilepsy:*

Yes

No

Fainting or Dizziness:*

Yes

No

Glaucoma:*

Yes

No

Headaches:*

Yes

No

Heart Murmur:*

Yes

No

Heart Problems:*

Yes

No

Hepatitis (Type):*

A

B

C

D

E

None

Herpes:*

Yes

No

High Blood Pressure:*

Yes

No

Jaundice:*

Yes

No

Jaw Pain:*

Yes

No

Kidney Disease:*

Yes

No

Liver Disease:*

Yes

No

Low Blood Pressure:*

Yes

No

Mitral Valve Prolapse:*

Yes

No

Nervous Problems:*

Yes

No

Pacemaker:*

Yes

No

Psychiatric Care:*

Yes

No

Radiation Treatment:*

Yes

No

Respiratory Disease:*

Yes

No

Rheumatic Fever:*

Yes

No

Scarlet Fever:*

Yes

No

Shortness of Breath:*

Yes

No

Sinus Trouble:*

Yes

No

Skin Rash:*

Yes

No

Special Diet:*

Yes

No

Stroke:*

Yes

No

Swollen Feet or Ankles:*

Yes

No

Swollen Neck Glands:*

Yes

No

Thyroid Problems:*

Yes

No

Tonsillitis:*

Yes

No

Tuberculosis:*

Yes

No

Tumor or Growth on Head or Neck:*

Yes

No

Ulcer:*

Yes

No

Venereal Disease:*

Yes

No

Weight Loss, Unexplained:*

Yes

No

Women

Are You Pregnant?

Yes

No

Due Date:

MM slash DD slash YYYY

Are You Nursing?

Yes

No

Taking Birth Control Pills?

Yes

No

Medications

List any medications you are currently taking and the correlating diagnosis:*

Pharmacy Name:

Phone:

Allergies

Aspirin:*

Yes

No

Barbiturates (Sleeping Pills):*

Yes

No

Codeine:*

Yes

No

Iodine:*

Yes

No

Latex:*

Yes

No

Local Anesthetic:*

Yes

No

Penicillin:*

Yes

No

Sulfa:*

Yes

No

Other:

Updates (To be filled in at future appointments)

Has there been any change in your health since your last dental appointment?

For What Conditions?

Are you taking any new medications?

If So, What?

Patient's Signature:

Date:

MM slash DD slash YYYY

Has there been any change in your health since your last dental appointment?

For What Conditions?

Are you taking any new medications?

If So, What?

Patient's Signature:

Date:

MM slash DD slash YYYY

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Comments

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