Patient Medical History

Patient's Name

For Office Use Only

Email address

Today's Date

Date of Last Visit

Date of Medical History

Address

City

State

Zip

Home Phone

Work Phone

Cell Phone

Birth Date

Social Security Number

Marital Status

Primary Dental Guarantor

Home Phone

Work Phone

Cell Phone

Secondary Dental Guarantor

Home Phone

Work Phone

Cell Phone

Physician Name

Physician Phone

Pharmacy

Pharmacy Phone

Medical Alerts

For Office Use Only

Sex

If female, please answer the following:

Are you taking Birth Control Pills?

Yes No

Are you pregnant?

Yes No

Are you nursing?

Yes No

If pregnant, how many weeks?

Do you smoke or use tobacco?

Yes No

Height

Weight

For Office Use Only

Heart Rate

For Office Use Only

Conditions

Please check all that apply.

Allergies

Aspirin

Codeine

Dental Anesthetics

Erythromycin

Jewelry

Latex

Metals

Penicillin

Tetracycline

Add additional allergies

Add additional medications

Add additional surgeries

Emergency Contact

Phone Number

Add secondary insurance

Disclaimer: By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Signature

Date

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