www.gomezfamilydentist.com - Patient Information Form - 27 - 03

Medical History Update Form

We are pleased to welcome you back to our practice. Please take a few minutes to 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
Name*

First NameMiddle NameLast Name
Social Security Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone Number
Please enter a valid phone number.
Cell Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Sex*
Date of Birth*

MonthDayYear
Marital Status
Patient employed by
Occupation
Business Phone Number
Please enter a valid phone number.
How did you hear about our office?
Emergency Contact
Notify in case of emergency*
Contact Phone Number*
Please enter a valid phone number.
Medical History
Physician’s Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Physician’s Email
example@example.com
Date of last visit

MonthDayYear
Date
Have you ever had any serious illnesses or operations?*

YesNo
If Yes, Describe*
Are you currently under physician care?*

YesNo
If Yes, Describe*
Women Only
Are you pregnant?*

YesNo
Nursing?*

YesNo
Taking birth control pills?*

YesNo
Check "Yes" or "No" if you have or have not had the following.
AIDS / HIV Positive*

YesNo
Anaphylaxis*

YesNo
Anemia*

YesNo
Arthritis*

YesNo
Artificial Heart Valves*

YesNo
Artificial Joints*

YesNo
Where*
Asthma*

YesNo
Back Problems*

YesNo
Blood Disease*

YesNo
Cancer*

YesNo
Type*
Chemical Dependency*

YesNo
Chemotherapy*

YesNo
Circulatory Problems*

YesNo
Cortisone Treatments*

YesNo
Persistent Cough*

YesNo
Cough up Blood*

YesNo
Diabetes*

YesNo
Epilepsy*

YesNo
Fainting*

YesNo
Food Allergies*

YesNo
Glaucoma*

YesNo
Headaches*

YesNo
Heart Murmur*

YesNo
Heart Problems*

YesNo
Herpes*

YesNo
Hepatitis*

YesNo
High Blood Pressure*

YesNo
Jaw Pain*

YesNo
Kidney Disease*

YesNo
Liver Disease*

YesNo
Latex Allergy*

YesNo
Mitral Valve Prolapse*

YesNo
Nervous Problems*

YesNo
Osteoporosis*

YesNo
Pacemaker / Heart Surgery*

YesNo
Psychiatric Care*

YesNo
Radiation Treatment*

YesNo
Respiratory Disease*

YesNo
Rheumatic Fever*

YesNo
Scarlet Fever*

YesNo
Shingles*

YesNo
Shortness of Breath*

YesNo
Skin Rash*

YesNo
Spina bifida*

YesNo
Stroke*

YesNo
Surgical Implant*

YesNo
Swelling of Feet and Ankles*

YesNo
Thyroid Disease*

YesNo
Tobacco use*

YesNo
Tuberculosis*

YesNo
Ulcer / Colitis*

YesNo
Venereal Disease*

YesNo
Other*

YesNo
If "Other" Please Explain*
List medications you are currently taking
List of any drug allergies
Authorization
I have reviewed the information on this questionnaire and it is accurate to the best of my knowledge. I understand that this information will be used by the dentist to help determine appropriate and helpful dental treatment. If there is any change in medical status, I will inform the dentist.

I authorize my insurance company to pay the dentist or dental group all insurance benefits otherwise payable to me for services rendered. I authorize the use of this signature on all insurance submissions.

I authorize the dentist to release all information necessary to secure the payment of benefits. I understand that I am financially responsible for all charges not paid by insurance and that payment in full (Patient portion) is due at the time of treatment.
I authorize Gomez Family Dentistry to discuss treatment, payment, and health related information that pertains to my treatment with the following people (Please List):
Signature*

Clear
Name*

First NameLast Name
Date*

MonthDayYear
Date
Should be Empty: