Medical History Form

Patient's Name:

Date of Birth:

Sex:

Ethnicity:

Email Address:

Home phone:

Work phone:

Mailing address:

City:

State:

Zip:

Employer:

Occupation:

Spouse's Name:

Spouse's Employer:

Unmarried

Whom may we thank for referring you to our office?

Phone book

BILLING, CREDIT, AND INSURANCE INFORMATION

Covered by Dental Insurance?

Yes No

Your Social Security Number:

Dental Insurance Co.

Group Number:

Covered by Spouse's Insurance?

Yes No

Spouse's dental insurance company:

Group Number:

Spouse's Birthday:

Social Security Number:

Medical Health History

Do you smoke or use chewing tabacco?

Yes No

Are you allergic to, or have you reacted adversely to any of the following?

Latex materials

Penicillin or other antibiotics

Local anesthetics ("Novocain")

Codeine or other narcotics

Sulfa drugs

Barbiturates, sedatives, or sleeping pills

Aspirin

Other:

Are you taking any of the following?

Aspirin

Anticoagulants (blood thinners)

Antibiotics or sulfa drugs

High blood pressure medicine

Antidepressants or tranquilizers

Insulin, Orinase, or other diabetes drugs

Nitroglycerin

Cortisone or other steroids

Osteoporosis (bone density) medicine

Other:

Women:

Taking hormones or contraceptives May be pregnant

If yes, Expect delivery date:

Name of your physician:

Do you have any disease, condition, or problem not listed above?

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/Name of patient (or parent):

Date:

Your information will be encrypted.