Medical History Form

Click Here (Patient Information/Health History) to download a printable copy of the form in PDF format.

Please fill in as many fields as possible. All fields marked with an asterisk (*) are required.

    Personal Information

     

    Female / Male: MaleFemale

     

    Contact Information

     


    If you have no telephone, please list a telephone number of a neighbor.

     



     

     

    Child Section (Ages 17 and Under)

     







     



     

     

    Adult Section (Ages 18 and Up)

     

    Marital Status (Select One) :  SingleMarriedWidowedDivorced

     





     



     

     

    Insurance

     

    Do you have dental insurance?   YesNo
    (If Yes, please complete the following insurance questions)

     











     

    Have you ever had any of the following? Please Check YES or NO for Every* question.

     

    Allergies:   YesNo
    Anemia:   YesNo
    Arthritis:   YesNo
    Asthma:   YesNo
    Bleeding Problems:   YesNo
    Blood Transfusions:   YesNo
    Cancer Treatment:   YesNo
    Chemotherapy:   YesNo
    Cold Sores:   YesNo
    Diabetes:   YesNo
    Dizziness:   YesNo
    Epilepsy:   YesNo
    Fainting:   YesNo
    Heart Attack:   YesNo
    Heart Defect(i.e. murmur):   YesNo
    Heart Disease:   YesNo
    Heart Surgery:   YesNo
    Heart Valve Replacement:   YesNo
    Hepatitis:   YesNo
    Herpes:   YesNo
    High Blood Pressure:   YesNo
    HIV Positive:   YesNo
    Joint Replacement Surgery:   YesNo
    Kidney Treatment:   YesNo
    Latex Allergy:   YesNo
    Metal Allergies:   YesNo
    Mitral Valve Prolapse:   YesNo
    Radiation Treatment:   YesNo
    Rheumatic Fever:   YesNo
    Seizures:   YesNo
    Stroke:   YesNo
    Tuberculosis:   YesNo
    Venereal Disease:   YesNo

     
     

    Do you experience redness or itching with wearing of certain jewelry? YesNo

    Do you experience itching or burning around the outside of your mouth following your dental visits? YesNo

    Are you allergic to kiwi or strawberries?   YesNo

    Are you pregnant?   YesNo

    Breast feeding?   YesNo

     



     

     

    Signature

     

    (Signature of Patient, if adult. If Patient is under 18 years of age, parent or guardian must sign.)

     

    I understand that I am responsible for my account regardless of my dental benefit plan. I also understand that my dental benefit plan is an agreement between me and my dental benefit plan company.
     
    I understand that I may be charged a 1.5% finance charge per month (18% Annually) if my balance goes beyond 90 days.
     
    I give permission for my dentist and clinical team to take any necessary radiographs and study models to make a complete diagnosis of my dental needs.

     

     

    You must 'check' the acceptance box in order to submit your information.
      I have read, agree to and understand the statements listed above.