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

Date

Best Number To Contact You

Please enter a valid phone number.Format: (000) 000-0000.

Emergency Contact Name And Number

What is your marital status?

How Did You Hear About Us?

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

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

Spouse Date of Birth

Spouses Date of Birth

Spouses Employer

Spouses Employer Name

Secondary Group Number

Secondary ID or Certificate Number

Secondary Certificate Number

Insurance EDI Submission Acknowledgement

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?

If you are taking any medications, please list them:

List None if you do not take medications

Are you fully vaccinated against COVID-19?

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?

If you answered Other on the previous question, please specify.

Do you have or have you had any of the following conditions?

When you walk up stairs or take a walk, do you ever have to stop because of pain in your chest?

Do your ankles swell during the day?

Do you use more than 2 pillows to sleep?

Have you ever experienced problems with healing?

Do you ever wake up from sleep short of breath?

Are you on a special diet?

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

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

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?

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?

If yes, please explain.

Do you have any allergies to latex/rubber products?

If yes, please explain.

Have you ever had a peculiar or adverse reaction to any medicines or injections?

If yes, please explain.

Have you ever been hospitalized for any illnesses or operations?

If yes, please explain.

Are you breastfeeding or pregnant?

If pregnant, what is the expected delivery date?

Do you smoke or chew tobacco products?

Do you identify as a patient with a disability?

If yes, please explain.

Consenting Signature

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

Date