drmowdds.com - Medical History Form

Medical History Form
Name

First NameMiddle NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
E-Mail Address
example@example.com
Social Security #
Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
Work Phone
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Sex
Date of Birth

MonthDayYear
Date
Height
Weight
Marital Status

Other
Name of Spouse
Closest Relative
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
May we contact your relatives listed above in case of an emergency?
Other Family Members Currently Patients?
Whom may we thank for referring you to our practice?
Name of person or office referring you to our practice:
Other
Health Information

For the following questions, please check whichever applies. Your answers are for our records only and will be considered confidential. Please note that during your initial visit you will be asked some questions about your responses to this questionnaire and there may be additional questions concerning your health.

Have you ever had any of the following? Please state date of occurrence.

Rows	Yes	No	Date of occurrence
Aids/HIV
Anemia
Arthritis
Artificial Joints
Asthma
Blood Disease
Blood Thinners/Aspirin
Cardiovascular Disease
Diabetes Type 1
Diabetes Type 2
Difficulty Breathing
Dizziness
Drug/alcohol Abuse
Epilepsy/Seizures
Excessive Bleed
Fainting
Glaucoma
Hay Fever
Head Injuries
Heart Disease
Heart Murmur
High Blood Pressure
Hypo/Hyper Thyroid
Jaundice
Kidney Disease
Liver Disease
Low Blood Pressure
Mental Disorders
Mitral Valve Prolapse
Nervous Disorders
Osteoporosis Meds
Pacemaker
Respiratory Problems
Rheumatic Fever
Rheumatism
Sinus Problems
Smoking/ Tobacco
Stomach Problems
Stroke
Tuberculosis
Tumors
Ulcers
Venereal Disease

Allergies
If yes, describe
Cancer
If yes, describe
Hepatitis
Type
Pregnancy
Due Date

MonthDayYear
Date
Are you allergic to:

Other
Do you have any disease, condition, or problem not listed above I should know about?
Explain:
Do you require any pre-medications prior to dental treatment?
Have you ever had any complications following dental treatment?
If yes, please explain:
Are you wearing removable dental appliances?
Have you been admitted to a hospital or needed emergency care during the past five years?
If yes, Please explain:
Are you under the care of a physician?
Physician’s name and number
If yes, what condition being treated?
Are you taking any medicine(s) including non-prescription medicine, drugs or alcohol?
If yes, what medicine(s) are you taking?
Responsible Party Information
Name:
Gender
Relationship to Patient:
Social Security #
Birth Date

MonthDayYear
Date
Phone (home):
Please enter a valid phone number.Format: (000) 000-0000.
Phone (work):
Please enter a valid phone number.Format: (000) 000-0000.
Phone (cell):
Please enter a valid phone number.Format: (000) 000-0000.
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Patient Employment Information
Subscriber’s Employer Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurance Information
Primary Insurance Information
Name of subscriber:
Is insured a patient?
Subscriber Birth Date:

MonthDayYear
Date
SSN:
Subscriber’s Employer Name:
Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurance Company:
Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Group #:
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Secondary Insurance Information
Name of subscriber:
Is insured a patient?
Subscriber Birth Date:

MonthDayYear
Date
SSN:
Subscriber’s Employer Name:
Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurance Company:
Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Group #:
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
I hereby authorize payment of the dental benefits otherwise payable to me directly to Dr. Mow D.D.S.
Signature (Employee/Subscriber)
Date

MonthDayYear
Date
Consent For Services

I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my medical status. I will not hold Dr. Mow or any other member of his staff responsible for any errors or omissions that I may have made in the completion of this medical history form.

I give my consent for dental treatment that the doctor indicates on the examination chart and any other dental treatment deemed necessary or advisable as a corollary to the planned dental treatment. I have been advised of all probable complications of the dental treatment.

If patient is a minor, I hereby grant permission for dental treatment to be performed on this minor and will assume all responsibilities connected with such treatment.

I understand that I am financially responsible for dental fees, with or without insurance payment.

I hereby authorize any insurance company to release all information with bearing on the benefits payable under this or any other plan providing benefits for services.
Signature of Patient or Parent if minor
Date

MonthDayYear
Date
Should be Empty:

Medical History Form

Responsible Party Information

Patient Employment Information

Insurance Information

Primary Insurance Information

Secondary Insurance Information