Patient Medical History Form

Patient's Name

Address

Today's Date

Date of Last Visit

Date of Medical History

City

State

Zip

Home Phone

Work Phone

Cell Phone

Birthdate

SS#

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

If female please answer the following:

If yes, # of weeks?

Please answer the following:

Height

Weight

Other

If other, please specify

Medications

Is there any disease, condition, or problem that you think this office should know about that is not covered above?

Yes No

If yes, please describe below...

Notes

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

Signature

Date

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