Medical History Form v2025

Medical History Form
Our goal is to help you reach & maintain good oral health & a beatiful smile
Patient Information
Name

Patient’s First NamePatient’s Last Name
Middle Name
Nickname
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Age
Gender:
Street Address
City
State
Zip Code
Emergency Contact Name
Emergency Contact Cell Phone:
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact Cell Phone Carrier
Patient’s Phone: (Optional)
Format: (000) 000-0000.
Patient’s Email (Optional)
example@example.com
School
Musical Instruments / Hobbies
Sports
Who is Accompanying the Patient Today?
Name of the person accompanying the Patient
Relationship to the Patient
Do you have legal custody of this Patient?
How did you hear about us?
List other family members seen by us
Physician & Dentist
Is the Patient under the care of a physician?
Name of General Physician
Name of General Dentist
Date of last dental visit / cleaning?

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Parent or Guardian Information (As Applicable)
Parent or Guardian (1)
Name of Parent or Guardian (1)
Birthdate of Parent Guardian (1)

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Relationship to Patient (1)
Contact Phone Person (1)
Format: (000) 000-0000.
Employer (1)
Job Title (1)
Parent or Guardian (2)
Name of Parent or Guardian (2)
Birthdate of Parent Guardian (2)

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Relationship to Patient (2)
Contact Phone Person (2)
Format: (000) 000-0000.
Employer (2)
Job Title (2)
Medical History Form
Our goal is to help you reach & maintain good oral health & a beatiful smile
Has the Patient ever had any of the following medical problems?
Abnormal Bleeding
Artificial Bones / Joints
Diabetes
ADD / ADHD
Hearing Impairment
Lupus
Allergies to any drugs
Rheumatic / Scarlet Fever
HIV / AIDS
Allergies to Latex/Metals
Congenital Heart Defect
Cancer
Allergies to Plastic
Asthma
Hepatitis
Hospital Stays
Epilepsy
Heart Murmur
Operations
Convulsions
Handicaps
Disabilities
If responded to “Yes” above, please explain as needed
Has the Patient ever experienced any of the following?
Clenching / Grinding Teeth
Tongue Thrust
Any pain/tenderness in joint
Lip Sucking/Biting
Thumb Sucking
Mouth Breathing
Finger sucking
Brush teeth daily
Nursing bottle habits
Nail biting
Injuries to the face, mouth, chin or teeth
Has puberty begun
History of missing teeth
Adenoids or Tonsils removed
Patient’s current health is:
Please list all the drugs that the patient is taking
If responded to “Yes” above, please explain as needed
Medical History Form
Our goal is to help you reach & maintain good oral health & a beatiful smile
Guarantor for Account / Insurance Subscriber
Name of Guarantor for this account
Guarantor's Date of Birth
Guarantor's relationship to the Patient
Is there any dental insurance available?
Guarantor's Contact Phone
Format: (000) 000-0000.
Is the Guarantor the primary subscriber of the dental insurance?
SS Number
Photos of Dental Insurance Card - Front

Cancelof
Photos of Dental Insurance Card - Back

Cancelof
Dental Insurance Information (if photo unavailable)
Name of Insurance Company
Subscriber ID Number
Group Number
Subscriber's Name
Subscriber's Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Subscriber's Employer
I understand that the information I have given is correct to the best of my knowledge, that it will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my Patient's medical status.
Medical History Form
Our goal is to help you reach & maintain good oral health & a beatiful smile
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Medical History Form

Patient Information

Who is Accompanying the Patient Today?

Physician & Dentist

Parent or Guardian Information (As Applicable)

Medical History Form

Has the Patient ever had any of the following medical problems?

Has the Patient ever experienced any of the following?

Medical History Form

Guarantor for Account / Insurance Subscriber

Medical History Form