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.Format: (000) 000-0000.
Emergency Contact Name And Number*
SingleMarriedCommon LawDivorcedWidowed
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*
YesNo
If you are taking any medications, please list them:*
List None if you do not take medications
YesNoPrefer Not to Answer
This is solely to keep your medical and drug history up to date.
AspirinPenicillinTetracyclineErythromycinOther AntibioticsCodeine or Other NarcoticsSedatives or Sleeping PillsLocal AnestheticsOtherNone of the Above
If you answered Other on the previous question, please specify.
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
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
If you answered "Yes" to the previous question, please specify.
YesNo
If you answered "Yes" to the previous question, please specify.
When was your last medical checkup?*
YesNo
If yes, please explain.
YesNo
If yes, please explain.
YesNo
If yes, please explain.
YesNo
If yes, please explain.
YesNo
If pregnant, what is the expected delivery date?
YesNo
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: