Medical & Dental History Form
Patient Name
First Name
MI
Last Name
Preferred Name
Indicate which of the following conditions you have or have had. By checking the box it will indicate a "YES" response, leaving blank will indicate a "NO" response.
ADD/ADHD/Lrng Disabi
Acid Reflux/GERD
Allergy- Aspirin
Allergy- Clindamycin
Allergy- Codeine
Allergy- Latex
Allergy- NSAIDs
Allergy- Penicillin
Allergy- Sulfa
Allergy-Local Anesth
Alzheimer's/Dementia
Anemia
Angina/Chest Pain
Arthritis
Asthma
Atrial Fibrillation
Autoimmune Disease
Back Problems
Biologic Medications
Bisphosonate Meds
Blood Disease
Blood Thinner Meds
Bruise Easily
Cancer
Celiac Disease
Chemical Dependency
Chemotherapy
Cold Sores
Crohns Disease
Depression/Anxiety
Diabetes
Dizziness/Fainting
Emphysema/COPD
Endocarditis
Epilepsy/Seizures
Excessive Bleeding
Fen-Phen Medications
Fibromyalgia
Glaucoma
HIV+/AIDS
Headaches
Heart Attack
Heart Bypass
Heart Disease
Heart Murmur
Heart Valve Replaced
Hepatitis -A
Hepatitis -B or C
High Blood Pressure
High Cholesterol
Hypoglycemia
Joint Replacement
Kidney Disease
Liver Disease
Low Blood Pressure
Menopause
Mitral Valve Prolapse
Osteopenia
Osteoporosis
PREMED
Pacemaker
Radiation Treatment
Rheumatic Fever
Rheumatism
STD / HPV
Seasonal Allergies
Sinus Problems
Sleep Apnea
Smoker/ Chew Tobacco
Stomach Problems
Stroke
Swelling of Limbs
TMJ/Joint Pain
Thyroid Condition
Tuberculosis
Tumors
Ulcers
FEMALE: Pregnant or Planning Pregnancy
FEMALE: Nursing
If any conditions or alerts selected above need further clarification, please describe below (including due date if pregnant):
Do you use Tobacco or Nicotine?
Yes
No
If yes, check all that apply;
Smoking
Chewing
Vaping
What is your estimate of your general health?
Excellent
Good
Fair
Poor
Do you take antibiotic premedication for your dental visits?
Yes
No
If yes, please explain below: PRE-MED
Are you taking any medications (prescription or non-prescription) including vitamins/supplements, aspirin, or birth control pills? ? If yes, please list below.
Yes
No
Please list any medications you are currently taking, one medication per line:
Have you taken or are you taking any Bisphosphonate drug used to treat osteoporosis or Paget's disease? Examples; Fosamax, Actonel, Boniva, Reclast, Didronel, Zometa, Prolia etc. If yes, please enter the drug in the Medications list above. *
Yes
No
Do you have any allergies not listed above (including allergies to medications)? If yes, please explain below *
Yes
No
Please list any Allergies not listed above. (medications, food, etc.)
Name and phone number of your Physician:
Name and phone number of preferred Pharmacy:
In an emergency who should be notified? Please enter the name, relationship to patient, and phone number below:
Describe any current medical treatment, recent hospitalizations and recent or impending surgery.
****FOR EXISTING PATIENTS ONLY****
PLEASE REVIEW AND MAKE ANY NECESSARY UPDATES
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Patient Name:
First Name
Middle Name
Last Name
Preferred Name:
Title:
Mr/Ms/Mrs/etc
Gender:
Male
Female
Family Status:
Married
Single
Child
Other
Birth Date:
-
Month
-
Day
Year
Date
Prev. Visit:
Email Address:
example@example.com
Home Phone:
Please enter a valid phone number.
Format: (000) 000-0000.
Mobile Phone:
Please enter a valid phone number.
Format: (000) 000-0000.
Work Phone:
Please enter a valid phone number.
Format: (000) 000-0000.
Ext.
Best time to call:
Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Dental Insurance
Primary Dental Insurance
Name of Insured:
First Name
Middle Name
Last Name
Patient's relationship to insured:
Self
Spouse
Child
Other
Insurance Plan Name:
Secondary Dental Insurance
Name of Insured:
First Name
Middle Name
Last Name
Patient's relationship to insured:
Self
Spouse
Child
Other
Insurance Plan Name:
*
To the best of my knowledge, all of the preceding information is true and correct. If I ever have a change in my health, I will inform the office at my next dental appointment without fail.
Please type name and date in box below.
Response Date:
-
Month
-
Day
Year
Date
Submit
Should be Empty: