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.