General Medical History Form

Welcome! The benefits of a happy, healthy smile are immeasurable! Our goal is to help you reach and maintain maximum oral health.
Please fill out this form completely. The better we communicate, the better we can care for you.

Name:

Prefer to be called:

Date:

05/16/2022

DOB:

Age:

Male

Female

Single

Married

Divorced

Widowed

Separated

Address:

E-mail Address:

Home Phone #:

Cell #:

Best time to reach you?:

Work #:

Ext:

DL #:

Who may we thank for referring you? / How did you hear about us?:

Name of previous/present dentist:

SSN#:

Last Visit Date:

Other family members seen by us:

Employer:

Employment Address:

Occupation:

How long employed there?:

Spouse Name:

DOB:

SSN#:

Spouse Employer:

Work #:

Ext:

DL #:

Person responsible for account:

Relationship:

Home Phone #:

SSN#:

Billing Address:

Employer:

Work #:

Ext:

DL:

Neighbor or relative not living with you:

Relation:

Work #:

Home Phone #:

Address:

Insurance

Primary Insurance

Dental?:

Yes

Insurance Phone:

Insurance Co.:

Insurance Address:

Group # (Plan, Local or Policy #):

Insured's Name:

Relation:

Insured's DOB:

Insured's ID#:

Insured's Employer:

Employer's Address:

Secondary Insurance

Dental?:

Yes

Insurance Phone:

Insurance Co.:

Insurance Address:

Group # (Plan, Local or Policy #):

Insured's Name:

Relation:

Insured's DOB:

Insured's ID#:

Insured's Employer:

Employer's Address:

Medical History

Physician's Name:

Phone #:

Date of last visit:

Currently under the care of a Physician?:

Yes

Explain:

Your current physical health is:

Good

Fair

Poor

Do you smoke or use tobacco in any other form?:

Yes

You ever taken Fosamax / other bisphosphonates?

Yes

Have you had any metal rods, pins or implants?:

Yes

Are you taking any prescription / over-the-counter or herbal supplemental drugs?:

Yes

Please list each one:

Have you been told you snore, hold your breath while sleeping, or wake-up gasping for breath?:

Yes

For Women: Are you using a prescribed method of birth control?:

Yes

Are you pregnant?:

Yes

Weeks?:

Are you nursing?:

Yes

Have you ever had any of the following diseases or medical problems?

Please list any serious medical condition(s) that you have ever had:

Are you allergic to any of the following?

Please list any other drugs/materials that you are allergic to:

Dental History

Why have you come to the dentist today?:

Do you require antibiotics before dental treatment?:

Yes

Are you currently in pain?:

Yes

Have you ever had a serious / difficult problem associated with any previous dental work?:

Yes

Do you have fears about going to the dentist?:

Yes

Have you ever had gum treatment?:

Yes

Do you no or have you ever experienced pain / discomfort in your jaw joint (TMJ / TMD)?:

Yes

Your current dental health is:

Good

Fair

Poor

I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my medical status. I have received a copy of this office's Notice of Privacy Practice.

Signature:

Date:

Payment is due in full at the time of treatment unless prior arrangements have been made.

If this office accepts insurance, I understand that I am responsible for payment of services rendered and also responsible for paying any co-payment and deductibles that my insurance does not cover. I hereby authorize payment directly to the Dental Office of the group insurance benefits otherwise payable to me. I understand that I am responsible for all the costs of dental treatment. I hereby authorize release of any information, including the diagnosis and records of treatment or examination rendered, to my insurance company.

Signature:

Date:

Our office is HIPAA Compliant and is committed to meeting or exceeding the standards of infection control mandated by OSHA and the ADA

OFFICE USE ONLY - OFFICE USE ONLY - OFFICE USE ONLY

I verbally reviewed the medical / dental information above with the patient named herein.

Initials:

Date:

Doctor's Comments:

Medical History Update

I have read my medical history dated:

and confirmed that it states past and present medical conditions.

Signature:

Date:

I have read my medical history dated:

and confirmed that it states past and present medical conditions.

Signature:

Date:

I have read my medical history dated:

and confirmed that it states past and present medical conditions.

Signature:

Date:

Patient Validation:

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