Medical History

Patient's Name Last

First

Pronouns

DOB

Social Security Number

Street Address

City

State

Zip

Phone Number

Dental Insurance Coverage

Employee Name

Relationship to Patient

SELF

SPOUSE

DEPENDENT

Employer Name

Insurance Company

Member Id#

1. Physician's Name

Address

Tel

2. Are you under a physician's care?

Yes No

Since when

Why

3. When was your last complete physical exam?

4. Are you taking any medication or substances?

Yes No

(If yes, please list medications in comments section or on the back of this form.)

5. Do you routinely take health related substances? (Vitamins, herbal supplements, natural products)

Yes No

6. Are you allergic to any medications or substances? (please list)

Yes No

7. Do you have any other allergies or hives?

Yes No

8. Do you have any problems with penicillin, antibiotics, anesthetics or other medications?

Yes No

9. Are you sensitive to any metals or latex?

Yes No

10. Are you pregnant or suspect you may be?

Yes No

11. Do you use any birth control medications?

Yes No

12. Have you ever been treated for or been told you might have heart disease?

Yes No

13. Do you have a pacemaker, an artificial heart valve implant, or been diagnosed with mitral valve prolapse?

Yes No

14. Have you ever had rheumatic fever?

Yes No

15. Are you aware of any heart murmurs?

Yes No

16. Do you have high or low blood pressure? (please circle)

Yes No

17. Have you ever had a serious illness or major surgery?

Yes No

If so, explain

18. Have you ever had radiation treatment, chemo treatment for tumor, growth or other condition?

Yes No

19. Have you ever taken Fosamax, Zometa, Aredia or any other oral or intravenous treatment (bisphosphonates) for bone tumors, excessive calcium in your blood, or osteoporosis?

Yes No

20. Do you have inflammatory diseases, such as arthritis or rheumatism?

Yes No

21. Do you have any artificial joints/prosthesis?

Yes No

22. Do you have any blood disorders, such as anemia, leukemia, etc?

Yes No

23. Have you ever bled excessively after being cut or injured?

Yes No

24. Do you have any stomach problems?

Yes No

25. Do you have any kidney problems?

Yes No

26. Do you have any liver problems?

Yes No

27. Are you diabetic?

Yes No

28. Do you have fainting or dizzy spells?

Yes No

29. Do you have asthma?

Yes No

30. Do you have epilepsy or seizure disorders?

Yes No

31. Do you or have you had venereal or any sexually transmitted disease?

Yes No

32. Have you tested HIV positive?

Yes No

33. Do you have AIDS?

Yes No

34. Have you had or do you test positive for hepatitis?

Yes No

35. Do you or have you had T.B.?

Yes No

36. Do you smoke, chew, use snuff or any other forms of tobacco?

Yes No

37. Do you regularly consume more than one or two alcoholic beverages a day?

Yes No

38. Do you habitually use controlled substances?

Yes No

39. Have you had psychiatric treatment?

Yes No

40. Have you taken any prescription drugs fenfluramine, fenfluramine combined with phentermine (fen-phen), dexfenfluramine (redux), or other weight loss products?

Yes No

41. Do you have any disease condition, or problem not listed? If so, explain

42. Is there anything else we should know about your health that we have not covered in this form?

43. Would you like to speak to the Doctor privately about any problem?

Yes No

Comments

I CERTIFY THAT THE ABOVE INFORMATION IS COMPLETE AND ACCURATE

Consent:

I consent to the diagnostic procedures and treatment by the dentist necessary for proper dental care.

I consent to the dentist's use and disclosure of my records (or my child's records) to carry out treatment, to obtain payment, and for those activities and health care operations that are related to treatment or payment.

My consent to disclosure of records shall be effective until I revoke it in writing. I authorize payment directly to the dentist or dental group of insurance benefits otherwise payable to me. I understand that my dental care insurance carrier or payer of my dental benefits may pay less than the actual bill for services, and that I am financially responsible for payment in full. By signing this statement, I revoke all previous agreements to the contrary and agree to be responsible for payment of services not paid, by my dental care payor.

PATIENT'S / GUARDIAN'S SIGNATURE

Date: