Patient Medical History Form

General Patient Information

KING FAMILY DENTAL CARE, P.A.
PATIENT NAME*

First NameMiddle NameLast Name
NAME YOU PREFERRED TO BE CALLED
EMAIL ADDRESS*
example@example.com
SOCIAL SECURITY NUMBER*
DRIVER'S LICENSE NUMBER*
DATE OF BIRTH*

MonthDayYear
HOME ADDRESS*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
MAILING ADDRESS (IF DIFFERENT THAN HOME)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
HOME PHONE NUMBER
Please enter a valid phone number if you have a landline.
CELL PHONE NUMBER
Please enter a valid phone number.
WORK PHONE NUMBER
Please enter a valid phone number if you have a work number.
EMPLOYER*
If you are currently employed. If not, please state "unemployed."
EMPLOYER ADDRESS

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
EMPLOYER PHONE NUMBER
Please enter a valid phone number only if you are currently employed.
OCCUPATION
Only if you are currently employed
MARITAL STATUS*
PARENT'S NAME

First NameLast Name
PARENT'S ADDRESS

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
PARENT'S HOME PHONE
Please enter a valid phone number If answered "unmarried" in previous question
PARENT'S CELL PHONE
Please enter a valid phone number If answered "unmarried" in previous question
SPOUSES NAME

First NameLast Name
SPOUSES CELL PHONE
Please enter a valid phone number
SPOUSES SOCIAL SECURITY NUMBER
SPOUSES EMPLOYER
SPOUSES WORK PHONE
Please enter a valid phone number
OTHER EMERGENCY CONTACT NAME*
CONTACT'S HOME PHONE*
Please enter a valid phone number
CONTACT'S CELL PHONE*
Please enter a valid phone number
RELATIONSHIP TO YOU*
ARE YOU COVERED BY DENTAL INSURANCE
PRIMARY INSURANCE COMPANY
If covered by dental Insurance
PRIMARY INSURANCE MAILING ADDRESS

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
POLICY HOLDER'S NAME
POLICY HOLDER'S DATE OF BIRTH

MonthDayYear
POLICY HOLDER'S SOCIAL SECURITY NUMBER
POLICY HOLDER'S EMPLOYER
RELATIONSHIP TO POLICY HOLDER
IF LISTED "OTHER" IN THE PREVIOUS QUESTION PLEASE STATE HOW YOU ARE RELATED TO THE POLICY HOLDER
ID #
POLICY #
GROUP #
*PLEASE NOTIFY OUR FRONT DESK IF YOU HAVE SECONDARY INSURANCE*
I AUTHORIZE TREATMENT OF THE PERSON NAMED ABOVE AND AGREE TO PAY ALL FEES AND CHARGES FOR TREATMENT. I ACKNOWLEDGE THAT I AM RESPONSIBLE FOR INFORMING KING FAMILY DENTAL CARE ABOUT ANY CHANGES IN MY HEALTH HISTORY PRIOR TO TREATMENT. PATIENTS WITH INSURANCE ARE RESPONSIBLE FOR THEIR PORTION OF THEIR BILL AT THE TIME OF SERVICE. KING FAMILY DENTAL CARE DOES NOT HAVE CONTRACTS WITH ANY INSURANCE CARRIERS, THEREFORE WE REQUIRE THAT YOUR ESTIMATED SHARE BE PAID NOW. I HEREBY AUTHORIZE PAYMENT OF MY GROUP INSURANCE BENEFITS TO KING FAMILY DENTAL CARE.
Signature*

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Date*

MonthDayYear
Date
HAS ANY MEMBER OF YOUR FAMILY VISITED OUR DENTAL CLINIC? IF YES, WHO?
HOW DID YOU HEAR ABOUT OUR CLINIC?*
IF YOU ANSWERED "FRIEND" OR "ANOTHER DENTIST" PLEASE PROVIDE THEIR NAME
TO THE PATIENT: Your answers are important for the protection of your health and that of the staff of King Family Dental Care. Please answer the following questions about your health. If you have now or have had any of the following conditions, special precautions may be needed during your dental treatment. Your answers are important for your treatment. ALL ANSWERS ARE STRICTLY CONFIDENTIAL
Patient Medical History
Please list any drug allergies
Have you ever had (Please check all that apply)

Congenital Heart LesionsDiabetes - Insulin DependentDiabetes - Diet ControlledHepatitis - Type A, B, C or DHigh Blood PressureHyperthyroidismKidney Disease/Transplant/DialysisLatex AllergyMalignant HyperthermiaPsychiatric Treatment - UndergoingSeizures and/or EpilepsyTuberculosis
HIV positive
If "Yes" enter the date of diagnosis
Stroke
If "Yes" enter the date(s)
Asthma
If "Yes", do you carry an inhaler?
Pregnant
If "Yes" state your current trimester & Ob/Gyn Physician
Do you smoke?
If "Yes" how much?
Do you use smokeless tobacco?
If "Yes" how often?
Do you drink alcohol?
Artificial Joint Replacement
If "Yes" state the type and date
Venereal Disease
If "Yes" state the type
Heart Attack
If "Yes" enter the date
Cancer
If "Yes" state the type
If "Yes" state the date of last Chemotherapy Treatment
If "Yes" state the date of last Radiation Treatment
Are you allergic to any medications? If "Yes", please list below
Heart Problems (If "Yes", please check any of the below that apply to you)

Heart MurmurBypass SurgeryPacemakerAngina PectorisRheumatic FeverArtificial ValvesMitral Valve Prolapse

Are you currently taking any medication? If "Yes", for what purpose? Please list below

	Purpose
Name of Drug
Name of Drug
Name of Drug
Name of Drug
Name of Drug

If needed, list any additional current medications & their purpose
Are you taking any of the following medications? (Check all that apply)

AsprinBirth Control PillsCortisone MedicineViagra
PLEASE NOTE: in combination with antibiotics your Birth Control Pills can become INEFFECTIVE.
If you take ASPRIN, how often and how much do you take?
Check any of the following that apply to you TODAY or in your past

AlcoholismAllergies/HivesAnemiaArthritisBirth DefectsBruise EasilyCold SoresCoughDizzy SpellsDrug AddictionEmphysemaGlaucomaLiver DiseaseMental IllnessHearing ImpairmentHemophiliaRheumatismScarlet FeverSickle Cell AnemiaThyroid DiseaseUlcers
Primary Physician's Name
Primary Physician's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Physician's Phone Number
Please enter a valid phone number.
Confirm Patient Name*

First NameLast Name
Date*

MonthDayYear
Date
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General Patient Information

Patient Medical History