MEDICAL HISTORY FORM

MEDICAL HISTORY
Please complete the following questions so that we may thoroughly diagnose your condition. The information you provide is for our records and will be considered strictly confidential. In addition, it is your responsibility to update this medical history when any changes occur.
1) Has there been any change in your general health within the past year?
- Yes
- No
1b) If Yes; Please specify medical changes:
2) Are you under the care of a physician for a current problem?
2b) Reason(s) for Physician Care
3) Have you been hospitalized within the past 5 years?
3b) Reason you were hospitalized and when.
4) Are you currently taking any medications or drugs?
4b) Please list drugs or medications
5) Have you received treatment for alcoholism or drug addiction within the past five years?
5b) If treated for alcoholism or drug addiction - list when
6) Have you ever had any ALLERGIC or ADVERSE REACTIONS to LATEX, anesthetics, antibiotics, or other medications?
6b) Please specify / list what caused reaction
7) Have you ever had abnormal bleeding with previous extractions, surgery, or trauma?
7b) If you ever had abnormal bleeding Please give details
8) Have you ever had a blood transfusion?
8b) Please explain Blood Transfusion
9) Have you ever had surgery and / or radiation for a tumor, growth or other condition
9b) List Condition(s)
10) Have you ever been tested for HIV (AIDS)
10b) Result of HIV Test: Date / indicate either Positive or Negative
11) Date of last Physical Exam
12) Do you have or had any of following (please check)
- High Blood Pressure
- Joint Prosthesis (hip, knee, etc)
- Congenital Heart Disease
- Do you have a pacemaker or a Cochlear Implant?
- Cardiovascular Disease: heart attack, stroke, by-pass
- Are you taking any blood thinners?
- prosthetic heart valve
- Blood Disorder (e.g. anemia)
- STD
- Asthma
- Temporomandibular Joint Problems (TMJ)
- Tobacco Use
- Sinus Trouble
- Thyroid Problems
- Diabetes
- Stomach Ulcers, Colitis
- Hepatitis, Jaundice, Liver Disease
- Kidney Problems
- Psychiatric Treatment
- Fainting Spells, or Seisures
- Epilepsy
- Cancer
- Are you currently or have you taken medicines for Osteoporosis?
- Delay in Healing
13) Do you have a disease, condition, or problem not listed above?
13b) Please list disease, condition or problem not listed above
14) Are you required to take premeds prior to dental treatment?
Women:
15) Are you pregnant?
16) Are you nursing?
17) Do you take birth control pills?
If yes to taking birth control pills, be advised that if you take antibiotics, an alternative method of birth control must be used.
All of the above information is true to the best of my knowledge.
Date
MM slash DD slash YYYY
Signature of Patient
Signature
PATIENT INFORMATION
Patient name
last First
Social Security XXX-XX-XXXX
Address
Street Address City State ZIP Code
Home Phone
Email
Business Phone
Cell Phone
Sex (Gender)
Age
Birthdate
Marital Status
Patient Employed by
Occupation
Whom may we thank for referring you?
In Case of Emergency who should be notified?
Emergency Contact Phone
PRIMARY INSURANCE
Person Responsible for Account
Last First
Relation to Patient
Birthdate
Social Security XXX-XX-XXXX
Address (if Different from patient's:
Street Address City state ZIP Code
Person Responsible Employed by
Occupation
Business Address
Bus Phone
Cell Phone
Insurance Company
Subscriber ID #
Group #
Secondary Insurance
Is Patient covered by additional insurance?
Name of Insured
Relation to patient
Birthdate
Address (if different from patient's)
Street Address City State ZIP Code
Employer
Bus Phone
Insurance Company
SS# or Subscriber ID #
Group #
Method of Payment
Which of the following methods of payment will you be using? (fees must be paid in full at the completion of treatment.)
Method of Payment:
All information is true and complete.

Signature
Date
MM slash DD slash YYYY
If dental insurance applies: Although this office files insurance claims as a service to the patient, the insurance contract is between the patient and the insurance company. As we have no control over the insurance company's method of payment or amount of payment, any difference of payment is entirely the responsibility of the patient.
INITIALS:

MEDICAL HISTORY FORM

MEDICAL HISTORY

Women:

If yes to taking birth control pills, be advised that if you take antibiotics, an alternative method of birth control must be used.

All of the above information is true to the best of my knowledge.

PATIENT INFORMATION

PRIMARY INSURANCE

Secondary Insurance

Method of Payment