"Dental Medical History Form"

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Date ______________________
MEDICAL HISTORY FORM
Patient Information:
Patient’s Name: _______________________________________________________________________________________
Last
First
Middle Initial
Address: ____________________________________________________________________________________________
Address
City
State
Zip Code
Email Address: ____________________ SSN: ______ - ____ - _____ Date of Birth: ______/ _____ / ____ Age: _____
Sex: o M o F
Home No: _________________ Cell No: ___________________ Alt. No: ____________________
Parent/Guardian Insurance Information:
Relationship to Patient: __________________
o SELF
Name: ______________________________________________________________________________________________
Last
First
Middle Initial
SSN: ______ - _____- _________
Insurance No.: ______________
Driver License No.: _____________________
Date of Birth: ______ / ____ / _______
Insurance Telephone No.: ____________
Group No.: _________________
Employer: ________________________
Address: _______________________________________________________
Home No: ________________________
Cell No: __________________________
Work No: __________________
Name and Number of nearest relative not living with you: ____________________________________________________
How did you hear about us? Please mark below:
o Yellow Pages
o Friend / Relative
o Flyers / Mail
o Internet
o Sign
o THMP-Medicaid
o Health Fairs / Screenings
o Other (Specify)
o Employee
o Insurance / Employer
o TV Ad-Which Station? _________
___________________________
o Bill Board
Reason for today’s dental visit: ______________________Date of last dental visit: ______________________
Have you ever had an experience in a dental office that you would like to tell us about? o Yes o No
Please explain if yes: _________________________________________________________________________
Are you nervous about dental treatment?
Do your gums bleed, feel tender or irritated?
Are you unhappy with appearance of your teeth?
o Yes
o No
o Yes o No
o Yes
o No
Are your teeth sensitive?
Do you have discolored teeth that bother you?
o Yes
o No
o Yes o No
If yes, to what?
o Sweets
o Hot
o Cold
o Pressure
Are you now seeing a physician?
o Yes
o No
The name & telephone number of your physician(s)____________________________________
If so, what is the condition being treated? ____________________________________________________________________________________________
Are you taking any medications?
o Yes
o No
If yes, please list: _________________________________________________________
o Yes
o No
Have you or are you currently taking Aspirin?
If female, are you or do you suspect to be pregnant? o Yes
o No
Months: _______________________________________________________________
Have you or are you currently taking oral Bisphosphates?
o Actonel o Boniva o Fosamax
o Skelif
o Didrone
o Other _____________________
o Yes
o No
Have you had any joint replacements?
If yes, when? ____________________________________________________________
Is there anything else we should know about your health that was not covered on this form? o Yes o No
If yes, Please explain: _________________________________________________________________________________________________________
Please mark any of the following which you have had or have at present:
o NONE
o Heart Disease
o Anemia
o Nervousness
o HIV + AIDS
o Heart Murmur
o Kidney Trouble
o Thyroid Disease
o Hepatitis
o High Blood Pressure
o Bone Loss
o Chemo: (Cancer, Leukemia)
o Hemophilia
o Blood Disease
o Epilepsy or Seizures
o Arthritis
o Sickle Cell Disease
o Rheumatic Fever
o Ulcers
o Rheumatism
o Bruise Easily
o Venereal Disease
o Emphysema
o Cortisone Medicine
o Pain in Jaw Joint
o Heart Pacemaker
o Tuberculosis
o Joint Replacement
o Diabetes
o Asthma
o Scarlet Fever
o Hay Fever
o Glaucoma
Please mark any of the following medical allergies:
o NONE
o Local Anesthetics
o Penicillin
o Codeine or other narcotics
o Fen-Phen
o Aspirin
o Other antibiotic:
o Barbiturates or sedatives
o Other: ___________________
o Iodine
o Sulfa Drugs
o Latex
o Other: ___________________
To the best of my knowledge, all of the preceding answers are true and correct. If I ever have any change in my health,
or if any medicines change, I will inform my dentist at the next appointment.
Signature of Patient/Parent/Guardian
Medical History Update:
Dr.
Date
Dr.
Date
Dr.
Date
Date ______________________
MEDICAL HISTORY FORM
Patient Information:
Patient’s Name: _______________________________________________________________________________________
Last
First
Middle Initial
Address: ____________________________________________________________________________________________
Address
City
State
Zip Code
Email Address: ____________________ SSN: ______ - ____ - _____ Date of Birth: ______/ _____ / ____ Age: _____
Sex: o M o F
Home No: _________________ Cell No: ___________________ Alt. No: ____________________
Parent/Guardian Insurance Information:
Relationship to Patient: __________________
o SELF
Name: ______________________________________________________________________________________________
Last
First
Middle Initial
SSN: ______ - _____- _________
Insurance No.: ______________
Driver License No.: _____________________
Date of Birth: ______ / ____ / _______
Insurance Telephone No.: ____________
Group No.: _________________
Employer: ________________________
Address: _______________________________________________________
Home No: ________________________
Cell No: __________________________
Work No: __________________
Name and Number of nearest relative not living with you: ____________________________________________________
How did you hear about us? Please mark below:
o Yellow Pages
o Friend / Relative
o Flyers / Mail
o Internet
o Sign
o THMP-Medicaid
o Health Fairs / Screenings
o Other (Specify)
o Employee
o Insurance / Employer
o TV Ad-Which Station? _________
___________________________
o Bill Board
Reason for today’s dental visit: ______________________Date of last dental visit: ______________________
Have you ever had an experience in a dental office that you would like to tell us about? o Yes o No
Please explain if yes: _________________________________________________________________________
Are you nervous about dental treatment?
Do your gums bleed, feel tender or irritated?
Are you unhappy with appearance of your teeth?
o Yes
o No
o Yes o No
o Yes
o No
Are your teeth sensitive?
Do you have discolored teeth that bother you?
o Yes
o No
o Yes o No
If yes, to what?
o Sweets
o Hot
o Cold
o Pressure
Are you now seeing a physician?
o Yes
o No
The name & telephone number of your physician(s)____________________________________
If so, what is the condition being treated? ____________________________________________________________________________________________
Are you taking any medications?
o Yes
o No
If yes, please list: _________________________________________________________
o Yes
o No
Have you or are you currently taking Aspirin?
If female, are you or do you suspect to be pregnant? o Yes
o No
Months: _______________________________________________________________
Have you or are you currently taking oral Bisphosphates?
o Actonel o Boniva o Fosamax
o Skelif
o Didrone
o Other _____________________
o Yes
o No
Have you had any joint replacements?
If yes, when? ____________________________________________________________
Is there anything else we should know about your health that was not covered on this form? o Yes o No
If yes, Please explain: _________________________________________________________________________________________________________
Please mark any of the following which you have had or have at present:
o NONE
o Heart Disease
o Anemia
o Nervousness
o HIV + AIDS
o Heart Murmur
o Kidney Trouble
o Thyroid Disease
o Hepatitis
o High Blood Pressure
o Bone Loss
o Chemo: (Cancer, Leukemia)
o Hemophilia
o Blood Disease
o Epilepsy or Seizures
o Arthritis
o Sickle Cell Disease
o Rheumatic Fever
o Ulcers
o Rheumatism
o Bruise Easily
o Venereal Disease
o Emphysema
o Cortisone Medicine
o Pain in Jaw Joint
o Heart Pacemaker
o Tuberculosis
o Joint Replacement
o Diabetes
o Asthma
o Scarlet Fever
o Hay Fever
o Glaucoma
Please mark any of the following medical allergies:
o NONE
o Local Anesthetics
o Penicillin
o Codeine or other narcotics
o Fen-Phen
o Aspirin
o Other antibiotic:
o Barbiturates or sedatives
o Other: ___________________
o Iodine
o Sulfa Drugs
o Latex
o Other: ___________________
To the best of my knowledge, all of the preceding answers are true and correct. If I ever have any change in my health,
or if any medicines change, I will inform my dentist at the next appointment.
Signature of Patient/Parent/Guardian
Medical History Update:
Dr.
Date
Dr.
Date
Dr.
Date
NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW MEDICAL/PROTECTED HEALTH INFORMATION ABOUT YOU MAY BE USED
AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
SUMMARY:
By law we are required to provide you with our Notice of Privacy Practices (NPP). This notice describes how
your medical information may be used and disclosed by us. It also tells you how you can obtain access to this
information.
As a patient you have the following rights:
1. The right to inspect and copy your information;
2. The right to request corrections to your information;
3. The right to request that your information be restricted;
4. The right to request confidential communications;
5. The right to report of disclosures of your information; and
6. The right to a paper copy of this Notice.
We want to assure you that your medical/protected health information is secure with us. This Notice of Privacy
Practice contains information about how we will insure that your information remains private.
Please list all telephone numbers where we may contact you:
1.__________________________2. ____________________________3. ______________________________
4. _________________________5. ____________________________6. ______________________________
PLEASE LIST THE NAMES OF ALL PEOPLE (e.g. SPOUSE, PARENTS, GRANDPARENTS, ETC...) YOU AUTHORIZE
US TO RELEASE YOUR HEALTH INFORMATION TO, INCLUDING COPIES OF YOUR RECORDS IF NEEDED:
Name ___________________________________________Relationship _______________________________
Name ___________________________________________Relationship _______________________________
Name ___________________________________________Relationship _______________________________
Name ___________________________________________Relationship _______________________________
Acknowledgement of Notice of Privacy Practice
I hereby acknowledge that I have reviewed this practice’s Notice of Privacy Practice. I further understand
that the practice will offer me updated to this Notice of Privacy Practice. Should it be amended, modified or
changed in any way I will receive a copy.
Printed Name of Patient
Signature of Patient/Parent/Guardian
FOR OFFICE USE ONLY
qPatient refused to sign
qPatient was unable to sign because: _________________________
Date: _______________Signature:___________________________
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