Medical History Form | Regis Court Dental Associates

First name*

Middle Initial*

Last Name*

Nickname

Street Address*

City*

State*

Zip Code*

Home Phone*

Cell Phone

Work Phone

Email*

Date of Birth*

Gender*

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

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

Zip Code

Insurance Company Phone Number

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

Zip Code

Insurance Company Phone Number

Physician's First Name

Physician's Last Name

Physician's Street Address

City

State

Zip Code

Physician's Phone Number

Does your physician require antibiotic premedication prior to dental procedures?* Yes No

Patient's Weight*

Are you allergic to the following?

If other, please explain.*

Please check any of the following that you have had or currently have

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?

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

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

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

THANK YOU!

You just completed the Medical History Form, we hope to get a hold of you soon!

Patient Information

General Information

How did you hear about our office?

Dental Insurance Information

If you have secondary insurance, Click Here and please fill out the information below.

Medical History

Please check any of the following which apply to you, and add any relevant comments.

Are you allergic to the following?

Please check any of the following that you have had or currently have

Dental History

What concerns you most about your teeth?

Please check any of the following which apply to you, and add any relevant comments

Emergency Visit