drexelhillendodontics.com - Medical History Form

Medical History Form
We are pleased to welcome you to our practice. Please take a few minutes and fill out this form as completely as you can. If you have questions we'll be glad to help you. We look forward to working with you in maintaining your dental health.
Patient Information
Mr.Mrs.Ms.Dr.Miss
Date

MonthDayYear
Date
Name

First NameMiddle NameLast Name
Home Phone
Please enter a valid phone number.
Cell Phone
Please enter a valid phone number.
Soc. Sec. #
Nickname
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Sex

MaleFemale
Age
Birthdate

DayMonthYear
Date
Marital Status

SingleMarriedDivorcedWidowedSeparated
Patient Employed by
Ocuppation
Business Address
Business Phone
Please enter a valid phone number.
Ext.
Referring dentist's name
May we call you at work?

YesNo
In case of emergency who should be notified?
Phone Number
Please enter a valid phone number.
Spouse
Children
Person financially responsible for account

First NameMiddle NameLast Name
Primary Dental Insurance
Subscriber Name
Relation to Patient
Birthdate

MonthDayYear
Date
Soc. Sec. #
Phone Number
Please enter a valid phone number.
Address (if different from patient)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Person Responsible Employed by
Occupation
Business Address
Business Phone
Please enter a valid phone number.
Ext.
Insurance Company
Insurance Address
Policy Number
Group Number
Subscriber Number
Name of other dependents covered in this plan
Additional Dental Insurance
Is patient covered by additional dental insurance?

YesNo
Subscriber Name
Relation to Patient
Soc. Sec. #
Phone Number
Please enter a valid phone number.
Address (if different from patient)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Subscriber Employed by
Business Phone
Please enter a valid phone number.
Ext.
Insurance Company
Insurance Address
Policy Number
Group Number
Subscriber Number
Name of other dependents covered in this plan
Health History
Physician's Name
Phone Number
Please enter a valid phone number.
Date of last visit

MonthDayYear
Date

Choose "Yes" or "No" to indicate if you have had any of the following.

	Yes	No
1. AIDS
2. Alcohol/Drugs Addiction
3. Anemia
4. Arthritis, Rheumatism
5. Artificial Heart Valves
6. Artificial Joints
7. Asthma
8. Back Problems
9. Bleeding abnormally, with extractions or surgery
10. Blood Disease
11. Cancer
12. Chemotherapy
13. Circulatory Problems
14. Congenital Heart Lesions
15. Cough, persistent of bloody
16. Diabetes
17. Emphysema
18. Do you wear contact lenses
19. Epilepsy
20. Fainting or dizziness
21. Glaucoma
22. Headaches
23. Heart Attack
24. Heart Murmur
25. Heart Problems
26. Herpes
27. High Blood Pressure
28. HIV Positive
29. Injury to head/neck
30. Jaundice
31. Kidney Disease
32. Liver Disease
33. Low Blood Pressure
34. Mitral Valve Prolapse
35. Nervous Problems
36. Pacemaker
37. Psychiatric Care
38. Radiation Treatment
39. Respiratory Disease
40. Rheumatic Fever
41. Shortness of Breath
42. Sinus Trouble
43. Special Diet
44. Stomach, Intestinal Disease
45. Stroke
46. Surgery
47. Swelling of Feet or Ankles
48. Swollen Neck Glands
49. Thyroid Problems
50. Tonsillitis
51. Tuberculosis
52. Tumor or growth on head or neck
53. Ulcer
54. Venereal Disease
55. Weight Loss, unexplained

56. Hepatitis

YesNo
Type
Hepatitis

YesNo
57. Woman: Are you pregnant?

Option 1Option 2Option 3
Due Date

MonthDayYear
Date
Woman: Are you Nursing?

YesNo
58. Other:
Medications
Have you ever had to medicate prior to dental visits?

YesNo
List medications you are currently taking?
Pharmacy Name
Phone Number
Please enter a valid phone number.
Allergies
YesNo
LatexPenicillinLocal AnestheticOther
Note: A change in your health status should be reported to the office at the earliest as possible time.
Authorization
To the best of my knowledge all questions have been answered correctly. I authorize my insurance company to pay to the dentist all insurance benefits otherwise payable to me for services rendered. I authorize the use of this signature on all insurance submissions. I understand that I am financially responsible for all charges whether or not paid by insurance. I grant the right to the dentist to release health information obtained from me, and information about my dental treatment to third party payers, and/or other health practitioners.
Person completing the form : Signature

Clear
Date

MonthDayYear
Date
Print Name
If other than patient, indicate relationship:
If patient is a minor I give consent for treatment necessery.
Signature

Clear
Relationship to Patient
PAYMENT IS DUE IN FULL AT TIME TREATMENT UNLESS PRIOR ARRANGEMENTS HAVE BEEN APPROVED.
PLEASE READ

Our policy is that payment shall be completed by your last visit. Please arrange this with our secretary. If your treatment is covered by insurance your copayment will be due by completion of the treatment. This is not a guarantee of benefits and any difference in insurance payment resulting from maximum exceeded, deductibles or coverage terminated, will be billed or refunded to you.

We shall try to advise as to the expected outcome, the number of appointments necessary, what you may expect from treatment, and the fee. Fees, once quoted, remain the same except:

1. When appointments are broken without 24 hour advance notification.
2. If surgery or retreatment becomes necessary.

When treatment is completed, your tooth will need a final restoration. Our fee does not include this service. Your dentist will render this service which is equally important to the preservation of your tooth. If not properly restored, your tooth may fracture or decay and be lost.
Should be Empty:

Medical History Form

Patient Information

Primary Dental Insurance

Additional Dental Insurance

Health History

Medications

Allergies

Authorization