Medical and Dental History
Patient Name
Date of Birth
Address
City
State
Zip
Email
Home Phone
Cell Phone
Marital Status
Minor
Single
Married
Divorced
Widowed
Emergency Contact Name
Phone
Insurance Information
Do you have dental insurance?
Yes
No
Name of Insured
Date of Birth
Social Security No.
Relationship to Patient
Name of Employer
Insurance Company Name
Insurance Company Phone
Group No.
Policy ID No.
Please upload a copy of
the front
of your Primary insurance card
Please upload a copy of
the back
of your Primary insurance card
Do you have secondary insurance?
Yes
No
Name of Insured
Date of Birth
Social Security No.
Relationship to Patient
Name of Employer
Insurance Company Name
Insurance Company Phone
Group No.
Policy ID No.
Please upload a copy of
the front
of your Secondary insurance card
Please upload a copy of
the back
of your Secondary insurance card
Medical History
Physician’s Name
Date of Last Visit
Physician Phone
Pharmacy Name
Phone
Please list all medications you are currently taking
Have you had a serious illness or operation?
Yes
No
Please Describe
Please indicate if you have had any of the following:
Anemia
Alzheimers/Dementia
Artificial Heart Valves
Blood transfusion
Chemotherapy/Radiation
Cancer
Cough, Persistent or Bloody
Emphysema/Asthma
Heart Problems
Headaches
High/Low Blood Pressure
HIV/AIDS
Joint Replacement
Organ transplant
Pacemaker
Psychiatric Care
Sinus Trouble
Tobacco use
Tonsillitis
Vertigo
Arthritis/Rheumatism
Blood Disorders
Taken Blood Thinners
Back Problems
Cortisone Treatments
Diabetes
Type
Epilepsy
Heart Attack
Date
Hepatitis
Type
Hypoglycemia
Jaw Pain
Mitral Valve Prolapse
Osteoporosis/Osteopenia
Rheumatic/Scarlet Fever
Seizures
Stroke
Date
Thyroid Problems
Tuberculosis
Are you allergic to:
Aspirin
Codeine
Latex
Sulfa
Barbiturates
Iodine
Penicillin
Local Anesthesia
Any other allergies that may affect your care?
Women:
Are you pregnant?
Yes
No
Are you nursing?
Yes
No
Do you take birth control pills?
Yes
No
To the best of my knowledge, the above information is complete and correct. I understand that it is my responsibility to inform my doctor if I, or my minor child, ever have a change in health.
Signature of Patient, Parent or Legal Guardian
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Date