DENTAL & MEDICAL HEALTH HISTORY
PATIENT INFORMATION
Name:
*
First Name
Middle Name
Last Name
Date of Birth:
*
-
Month
-
Day
Year
Date
Age:
Please Select
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Gender:
*
Male
Female
Address:
*
Street Address
Apt #
City
State / Province
Postal / Zip Code
Home Phone:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Cell Phone:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email:
*
example@example.com
PARENT INFORMATION IF PATIENT IS A MINOR
Mother/Father Name:
*
Phone Number:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Address if different from Child:
*
Caregiver Name:
*
Phone Number:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Address If different from child:
DENTAL INSURANCE INFORMATION PRIMARY CARRIER
Insured’s Name:
*
Date of Birth:
*
-
Month
-
Day
Year
Date
SSN:
*
Employer:
*
Policy Number/Member ID:
*
Insurance Co. Name:
*
Secondary Insurance :
Policy Number/Member ID:
DENTAL HISTORY
Please check the questions below if patient have/had:
*
Tooth Pain
Bad Breath
Blister on lips or mouth
Dry mouth
Food collection between teeth
Swollen or bleeding gums
Loose teeth or broken filings
Dental abscess
Tooth sensitivity to hot/cold
Clench or grind teeth
None of the above
Other
How many times a day do you floss?
*
How many times a day do you brush?
*
Date of Last Dental Exam:
*
-
Month
-
Day
Year
Date
Have you ever had an allergic reaction to local anesthesia or general anesthetics?
*
Yes
No
If yes, Please Explain:
*
MEDICAL HISTORY
Physician’s Name:
*
Physician Phone:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Please Yes or No
*
Rows
Yes
No
Abnormal Bleeding
Alcohol Abuse
Allergies
Anemia
Angina Pectoris
Arthritis
Artificial Bones
Artificial Heart Valve
Asthma
Blood Transfusion
Cancer- Chemotherapy
Colitis
Congenital Heart Defect
Cosmetic Surgery
Diabetes
Difficulty Breathing
Drug Abuse
Emphysema
Epilepsy
Fainting Spells
Glaucoma
HIV + AIDS
Hay Fever
Heart Attack
Heart Surgery
Hemophilia
Hepatitis A
Hepatitis B
High Blood Pressure
Kidney Problems
Liver Disease
Low Blood Pressure
Mitral valve Prolapse
Pace Maker
Pneumocystis
Psychiatric Problems
Radiation Therapy
Rheumatic Fever
Seizures
Shingles
Sickle Cell Disease
Thyroid Problems
Tuberculosis
Ulcers
Venereal Disease
Yellow Jaundice
Fever Blisters
Frequent Headaches
Sinus Problems
Stroke
ALLERGIES
*
Rows
Yes
No
Aspirin
Codeine
Dental Anesthetics
Erythromycin
Jewelry
Latex
Metals
Penicillin
Tetracycline
Other:
Back
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MEDICATIONS
List any medications that you are taking:
Is there any disease, condition, or problem that you think this office should know about that is not covered above?
Yes
No
If yes, Please describe:
(WOMEN ONLY)
Are you taking any birth control pills?
Yes
No
Are you pregnant?
Yes
No
If yes, # weeks:
Are you nursing?
Yes
No
AUTHORIZATION AND RELEASE
I have read and answered the above questions to the best of my knowledge.
Patient/Guardian Signature:
*
Date:
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: