Medical History Form

Date*

Date

Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

Your Name*

Your Address*

Your Height*

Your Weight*

Date of Birth*

Date

MaleFemale

Emergency Contact Name*

Relationship to Emergency Contact*

Emergency Contact Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

If you are completing this form for another person, what is your relationship to this person?

For the following questions, please (X) whichever applies, your answers are for our records only and will be kept confidential in accordance with applicable laws. 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. This information is vital to allow us to provide appropriate care for you. This office does not use this information to discriminate

YesNoI Dont Know

YesNoI don't know

How would you describe your current dental problem*

Date of your last dental exam*

Date

Date of last dental xrays*

Date

What was done at that time*

YesNoI don't know

Have you had any of the following diseases or problems?

YesNoI don't know

If yes, what is/are the conditions being treated?

YesNoI don't know

If yes, what was the illness or problem?

YesNoI don't know

If yes, what medicine(s) are you taking?

YesNoI don't know

If yes, specify which allergies and the reaction that occurs

YesNoI don't know

Please answer the following to indicate if you have or have not had any of the following diseases or problem.

YesNoI don't know

YesNoI don't knowType option 4

YesNoI don't Know

YesNoI don't know

Yes, Type 1Yes, Type 2NoI don't know

YesNoI don't know

Yes, EmphysemaYes, Bronchitis, etcNoI don't know

YesNoI don't know

If yes, please explain

NOTE: Both Doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment. I certify that I have read and understand the above. I acknowledge that my questions, if any, about inquiries set forth above have been answered to my satisfaction. I will not hold my dentist, or any other member of his/her staff, responsible for any action they take or do not take because of errors or omissions that I may have made in the completion of this form.

SIGNATURE OF PATIENT or LEGAL GUARDIAN *

Date*

Date

ADA