Health History Form
       

Thank you for visiting our office.  We want your visit to be pleasant and comfortable. Please help us by completing this form.

All of this information is completely confidential.

Patient Information

Full Name (Last, First, Initial):  
Preferred Name:
Address:
City State, Zip: ,
   
Phones: Home-    Work-    Cell-
E-mail Address:
Soc Sec #:
Sex:
Male Female
Date of Birth:
Marital Status:
Single Married Widowed Separated Divorced
Patient Employer/Occupation:
Emergency Contact:
Spouse's Name:
Spouse's Employer/Occupation:
How did you hear about our office?

Responsible Party Information

Person Financially Responsible:
Relation to patient:
   
Address:
City State, Zip: ,
   
Phones: Home-    Work-
Employer:
Soc Sec #:
Date of Birth:
 

Dental Insurance Information

Is patient covered by dental insurance?
Yes No
(If yes, please complete the following:)  
Policy Holder Name:
Relation to Patient:
Address:
City State, Zip: ,
Phones: Home-    Work-
Soc Sec #:
Date of Birth:
Insurance Company Name:
Insurance Company Phone:
Group #:
Subscriber ID#:
   
Is patient covered by additional dental insurance?
Yes No
(If yes, please complete the following:)  
   
Policy Holder Name:
Relation to Patient:
Address:
City State, Zip: ,
Phones: Home-    Work-
Employer:
Soc Sec #:
Date of Birth:
Insurance Company Name:
Insurance Company Phone:
Group #:
Subscriber ID#:

INSURANCE AUTHORIZATION & FINANCIAL RESPONSIBILITY AGREEMENT

 

I understand that I am financially responsible for all charges whether or not paid by insurance. I assign all insurance benefits directly to the doctor otherwise payable to me for services rendered. I hereby authorize the doctor to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all insurance submissions.
   
Signature (Parent/Guardian if under age 18) Relationship (if patient is under age 18) Date
 

Medical History

Patient Name:
Physician's Name:
Phone:
Date of Last Visit:
Please check the box if you have ever had any of the following:
AIDS or HIV positive Acid Reflux/ G.E.R.D Arthritis, (supply type below)
Artificial joints Asthma Cancer
Chemical Dependency Diabetes, (supply type below) Eating disorder
Epilepsy Excessive bleeding Glaucoma
Hepatitis, (supply type below) Kidney problems Liver problems or Jaundice
Lung or breathing problems Sinus trouble Smoking/chewing tobacco
Stroke Swollen neck glands Thyroid problems
Tuberculosis
Heart Problems: Allergies: Women:
Artificial valves
Congential heart defects
Heart Surgeries
High blood pressure
Infective (Bacterial) Endocarditis
Low blood pressure
Pacemaker
Other (Supply details below)

Antibiotics for dental treatment
Currently under a physician's care
Serious illnesses/hospitalizations
Aspirin
Codeine
Latex
Local anesthetic
Metals
Penicillin
Sulfa

Other Allergies: 
Are you pregnant? 
No
Yes

Due when? 
Are you nursing? 
No
Yes
Medications: Please list medications you are currently taking and why

Dental History (New Patients Only)

Checkmark if you have ever had any of the following:
Bad breath problem Biteguard / Nightguard Canker sores in mouth
Cold sores on outer lips Dental anesthetic problems Excessive gag reflex
Fear of dental care Frequent headaches, neck aches Full dentures / Partial dentures
Oral surgery Orthodontics (braces) TMJ, jaw joint pain or treatment
Gum disease treatment
Checkmark if you currently have any of the following:
Bleeding gums Broken tooth or filling Clenching or grinding of teeth
Clicking or popping jaw Dry mouth Food packing between teeth
Loose tooth Mouth breathing Pain
Sensitivity to - heat - cold - biting Sensitivity to - sweets - pressure Sores or growths in mouth
Swelling Tired, sore or painful jaw joint Toothache
Vague ache Pain around ear
Other:
Give details and location of the above checked items:
   
How often do you brush?
How often do you floss?
What type toothbrush do you use?
Ultrsoft Soft Medium Hard Electric
   
Reason for today's visit
Former Dentist , City/State:    Phone:
Date and reason of last dental visit:
Date of last dental X-rays:
   
What have you liked about any dental office you've been to?
What have you liked LEAST about any dental office you've been to?

TREATMENT AUTHORIZATION

I have reviewed the information on this form and it is accurate to the best of my knowledge. I authorize and give consent for the dentist and/or team of this office to perform dental services as agreed between doctor and patient and/or guardian, including the use of local anesthetic and other medication as indicated.

   
Signature (Parent/Guardian if under age 18) Relationship (if patient is under age 18) Date

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