THANK YOU! You just completed the Medical History Form, we hope to get a hold of you soon! Patient Information Fields marked with an asterisk (*) are required. General Information First name* Middle Initial* Last Name* Nickname Street Address* City* State* State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Code* Home Phone* Cell Phone Work Phone Email* Date of Birth* Gender* -- Select One -- Female Male Social Security Number Employer Occupation If the patient is a minor, please give parent's or guardian's name If the patient is a minor, please list the relationship to the patient How did you hear about our office? Referral Website Internet Search Engines Five for Women Magazine Volume One Magazine Insurance Phone Book Radio Other If you were referred, please let us know who referred you so that we can thank them!* If you heard us on the radio, please let us know which station:* Today's Country WAXX 104.5 I-94 Today's Best Variety News Talk WAYY 790 If other, please explain* Dental Insurance Information Insured's First Name Insured's Last Name Relationship to Insured Date of Birth Insured's SSN Insured's Employer Insurance Company Group Number ID/Subscriber Number Insurance Company's Street Address City State State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Code Insurance Company Phone Number If you have secondary insurance, Click Here and please fill out the information below. Insured's First Name Insured's Last Name Relationship to Insured Date of Birth Insured SSN Insured's Employer Insurance Company Group Number ID/Subscriber Number Insurance Company Address Insurance Company City Insurance Company State State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Code Insurance Company Phone Number Medical History Please fill out this section to the best of your knowledge. It is important for us to be aware of any health issues that may affect the treatment you receive from our office. This information is kept strictly confidential. Physician's First Name Physician's Last Name Physician's Street Address City State State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Code Physician's Phone Number Does your physician require antibiotic premedication prior to dental procedures?* Yes No Patient's Weight* Please check any of the following which apply to you, and add any relevant comments. Are you taking any medications?* Yes No If yes, please list all medications you are currently taking.* Do you have a history of any major illness?* Yes No If yes, please explain.* Have you had any major operations?* Yes No If yes, when did this occur and what was performed?* Have you ever been involved in a serious accident?* Yes No If yes, when?* Are you allergic to the following? Aspirin Penicillin Codeine Local Anesthetics Acrylic Metal Latex Other If other, please explain.* Please check any of the following that you have had or currently have AIDS/HIV Positive Abnormal Bleeding/Hemophilia Acid Reflux (GERD) Alzheimer's Disease Anaphylaxis Anemia Angina Arthritis/Gout Artificial Heart Valve Artificial Joint Asthma/Hay Fever Blood Disease Blood Transfusion Breathing Problem Bruise Easily Cancer Chemotherapy Chest Pains Cold Sores/Fever Blisters Congenital Heart Defect Convulsions Cortisone Medicine Diabetes Drug Addiction Easily Winded Emphysema Epilepsy or Seizures Excessive Thirst Fainting Spells/Dizziness Frequent Cough Frequent Diarrhea Frequent Headaches Genital Herpes Glaucoma Heart Attack/Failure Heart Murmur Heart Pacemaker Heart Troubles/Disease Hemophilia Hepatitis A Hepatitis B or C Herpes High Blood Pressure Hives or Rash Hypoglycemia Irregular Heartbeat Kidney Problems Leukemia Liver Disease Low Blood Pressure Lung Disease Mitral Valve Prolapse Pain in Jaw Joints Parathyroid Disease Psychiatric Care Radiation Treatments Recent Weight Loss Renal Dialysis Rheumatic Fever Rheumatism Scarlet Fever Shingles Sickle Cell Disease Sinus Trouble Spina Bifida Stomach/Intestinal Disease Stroke Swelling of Limbs Thyroid Disease Tonsillitis Total Joint Replacement Tuberculosis Tumors or Growths Ulcers Venereal Disease Yellow Jaundice When was the artificial Heart Valve placed?* When was the Artificial Joint placed?* When did you have the Blood Transfusion?* When were you last diagnosed with Cancer?* When was your last treatment of Chemotherapy?* When was you last Heart Attack/Failure?* When was the Heart Pacemaker placed?* When did you have the Stroke?* When did you have the Total Joint Replacement?* Are there any medical conditions we have not discussed that you feel we should be aware of? Do you use Tobacco* Yes No If yes, what kind? -- Select -- Cigarettes Chewing Tobacco Both Cigarettes and Chewing Tobacco If yes, how much?* Do you use controlled substances or have in the past?* Yes No Are you Pregnant or Trying to get Pregnant?* Yes No If you're pregnant, how many weeks?* Taking oral contraceptives* Yes No Nursing* Yes No Is your water fluoridated?* Yes No Dental History General Dentist Date of Last Visit What concerns you most about your teeth? Please check any of the following which apply to you, and add any relevant comments Are you presently in any dental pain? Have you ever lost or chipped any teeth? Have there been any injuries to face, mouth or teeth? Is any part of your mouth hot or cold sensitive? Is any part of your mouth sensitive to pressure? Are you a mouth Breather? Are you aware of your jaws clicking or popping? Are you aware of clenching your teeth during the day? Have you ever been told that you grind your teeth? Do you have "tension" headaches? Have you ever experienced chronic ringing in your ears? Are you fearful of dental visits? Are you interested in sedation dentistry? Are you interested in cosmetic dentistry? Have you ever experienced any unfavorable reaction to dentistry? Do your teeth or jaws ever feel uncomfortable when you awake in the morning? Please explain your dental pain.* Please explain the injury and any teeth that may have been affected.* Which part of your mouth is sensitive to hot or cold? (Your upper, lower, left or right)* Which part of your mouth is sensitive to pressure? (Your upper, lower, left or right)* Comments To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in medical status.
