Health History Form

PATIENT INFORMATION

PATIENT INFORMATION

Patient

Birthdate

Age

Address

City

State / Zip

Home #

Wk#

Cell #

Patient's Employer

E-mail Address

Person to contact for emergency?

Phone #

Which pharmacy do you use for prescriptions

Phone #

Whom may we thank for referring you to our office?

Are you available for short notice appt's?

When?

SPOUSE or RESPONSIBLE PARTY INFORMATION

SPOUSE or RESPONSIBLE PARTY INFORMATION

Name

Birthdate

S.S.N.

Address

City

State

Zip

Employer

Work #

Terms and Agreement

I understand that I am responsible for payment for Dental services provided in this office for myself or dependents. Payment is due at the time of services rendered I further understand that 1.5% finance charge (18% annually) will be added to any balance over 60 days. In the event of default I (we) promise to pay legal interest on the indebtedness, together with such collection costs and reasonable attorney fees as may be required to collect this debt.

Signature of person responsible for account.

INSURANCE INFORMATION

INSURANCE INFORMATION

Name of Insured

Employer

Insurance Company Name and #

Address

City

State

Zip

Birthdate

ID # / SS #

Group #

Patient's Relationship to insured

Self

Spouse

Child

Other

I have read this form and agree to be financially responsible.

I authorize payment of benefits directly to the provider.

I authorize the release of all information to the insuarance Co.

MEDICAL HEALTH INFORMATION

MEDICAL HEALTH INFORMATION

Name of your Doctor?

Phone

Address

City

State

Zip

Has there been any change in your health in the last year?

yes

no

not sure

If yes please explain.

Have you ever been hospitalized?

yes

no

not sure

If yes please explain.

Are you currently receiving treatment or regular medical care?

yes

no

not sure

If yes please explain.

Are you allergic to or had any unusual reactions to medications?

yes

no

not sure

If yes please explain.

Are you or have you had an addiction to alcohol or drugs?

yes

no

not sure

If yes please explain.

Have you used any drugs or alcohol in the last 24 hours?

yes

no

not sure

If yes please explain.

Are you presently taking or have you ever taken any of the following medications?

List any Medication you are presently taking

List any Medication you are presently taking:

Medication

Dosage

Date started

Reason you are taking medication

Medication

Dosage

Date started

Reason you are taking medication

Medication

Dosage

Date started

Reason you are taking medication

Have you ever had or been treated by a doctor for (check any conditions that apply)

Options

Do you use tobacco products?

Smoke?

How many

Dip? how often?

Free Text

WOMEN:

Are you pregnant or could you be prenant?

yes

no

not sure

Have you ever had any type of join replacements? Knee/hip

yes

no

not sure

If yes please explain.

Have you ever taken any of the following diet medications?

Redux

Pondimin

Phen/Phen

Are there any other problems about your health that you know of?

yes

no

not sure

If yes please explain.

DENTAL HISTORY

DENTAL HISTORY

When was you last dental visit and x-rays?

Who was your previous D.D.S.?

May we request your records?

What is the reason for your dental visit today?

What is your major dental concern?

Have you ever fainted during a dental visit?

yes

no

not sure

If yes please explain.

Have you experienced any reaction to any medication or anesthetic?

yes

no

not sure

If yes please explain.

Have you had nitrous oxide sedation?

yes

no

not sure

Was it a good experience?

yes

no

not sure

Have you had any other complications following dental treatment?

yes

no

not sure

If yes please explain.

Have you had any injury to your teeth, jaws, or face?

yes

no

not sure

If yes please explain.

Would you change anything about the appearances of your teeth?

yes

no

not sure

If yes please explain.

Do your gums bleed when you brush your teeth?

yes

no

not sure

Have you ever been told you have gum disease?

yes

no

not sure

Have you ever seen a periodontist?

yes

no

not sure

If yes please explain.

Are any of your teeth sensitive to hot, cold, or pressure?

yes

no

not sure

Do you experience pain or clicking in your jaw joints?

yes

no

not sure

Do you wear or have a night guard?

yes

no

not sure

Do you have or have you ever had partials/dentures or implants?

yes

no

not sure

Have you ever had orthodontic care?

yes

no

not sure

If yes when.

Have you ever had an allergic reaction to latex?

yes

no

not sure

Free Text

SIGNATURE OF PATIENT: I understand the need for truthful answers. To the best of my knowledge, the answers I have given are accurate. I also understand the importance to report any change in my medical/dental status to the dentist at the earliest possible time. I give my permission to the dentist to obtain any additional information from my physician.

SIGNATURE

DATE

If other than patient, indicate relationship

Contact Us