Medical History Form

Medical History Form
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Email*
example@example.com
Date of Birth*

MonthDayYear
Date
Best Number To Contact You*
Please enter a valid phone number.
Emergency Contact Name And Number*
What is your marital status?*

SingleMarriedCommon LawDivorcedWidowed
How Did You Hear About Us?*

GoogleInstagramWebsiteReferralOther
If you were referred to us, who referred you?
Do You Have Dental Insurance?*
If selected "other" for Dental Insurance, please explain:
Please Specify Your Insurance Company
Insurance Company*
Please Specify Your Insurance Company. If not applicable, write N/A.
Employee Name*
Employee Name. If not applicable, write N/A.
Employee Date of Birth*

MonthDayYear
Date
Employer*
Your Employer Name. If not applicable, write N/A.
Group Number*
Your Group Number. If not applicable, write N/A.
ID or Certificate Number*
Your Certificate Number. If not applicable, write N/A.
Do you have Secondary Insurance?*
Indicate if your Spouse has insurance. If Yes, please fill out the following below.
Secondary Insurance Company
Please Specify Your Secondary Insurance Company
Spouses Employee Name
Spouses Employee Name
Spouse Date of Birth

MonthDayYear
Spouses Date of Birth
Spouses Employer
Spouses Employer Name
Secondary Group Number
Secondary Group Number
Secondary ID or Certificate Number
Secondary Certificate Number
Insurance EDI Submission Acknowledgement*

Clear
I give Dr. Aurora Moldovan authorization to send my family's dental claims electronically
Physician Name And Number *
Pharmacy Name And Number*
Are you currently taking any medications?*

YesNo
If you are taking any medications, please list them:*
List None if you do not take medications
Are you fully vaccinated against COVID-19?*

YesNoPrefer Not to Answer
This is solely to keep your medical and drug history up to date.
Are you allergic to or have you reacted adversely to any of the following?*

AspirinPenicillinTetracyclineErythromycinOther AntibioticsCodeine or Other NarcoticsSedatives or Sleeping PillsLocal AnestheticsOtherNone of the Above
If you answered Other on the previous question, please specify.
Do you have or have you had any of the following conditions?*

High Blood PressureHeart TroubleMitral Valve ProlapseAngina PectorisHeart MurmurArtificial Heart ValveHeart SurgeryHeart AttackArtificial JointStomach UlcerSleep ApneaStrokeGlaucomaLiver DiseaseAnemiaHepatitis A/B/CExcessive BruisingYellow JaundiceThyroid DiseaseLeukemiaHemophilia or Blood TransfusionKidney TroubleHIV (AIDS)Venereal DiseaseCold SoresEmphysema/BronchitisPersistent CoughAsthmaTuberculosisDrug AddictionAlcohol DependencyHayfeverSinus TroublesFaintingEating DisorderPsychiatric TreatmentDiabetes or Excessive ThirstArthritisOsteoperosisCancerEpilepsy/SeizuresRheumatic or Scarlet FeverNone of the Above
When you walk up stairs or take a walk, do you ever have to stop because of pain in your chest?

YesNo
Do your ankles swell during the day?*

YesNo
Do you use more than 2 pillows to sleep?*

YesNo
Have you ever experienced problems with healing?*

YesNo
Do you ever wake up from sleep short of breath?*

YesNo
Are you on a special diet?*

YesNo
Has your medical doctor ever said you have cancer or a tumor?*

YesNo
Do you have any disease, condition, or problem not listed?*

YesNo
If you answered "Yes" to the previous question, please specify.
Are you currently being treated for any medical condition or have you been treated within the past year?*

YesNo
If you answered "Yes" to the previous question, please specify.
When was your last medical checkup?*
Has there been any change in your general health in the past year?*

YesNo
If yes, please explain.
Do you have any allergies to latex/rubber products?*

YesNo
If yes, please explain.
Have you ever had a peculiar or adverse reaction to any medicines or injections?*

YesNo
If yes, please explain.
Have you ever been hospitalized for any illnesses or operations?*

YesNo
If yes, please explain.
Are you breastfeeding or pregnant?*

YesNo
If pregnant, what is the expected delivery date?
Do you smoke or chew tobacco products?*

YesNo
Do you identify as a patient with a disability?*

YesNo
If yes, please explain.
Consenting Signature*

Clear
By entering your name here, you consent that the above information is correct to your knowledge.
Date*

MonthDayYear
Date
Should be Empty: