Health History Form

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 in Details Below)
Artificial joints	Asthma	Cancer
Chemical Dependency	Diabetes, (Supply Type in Details Below)	Eating disorder
Epilepsy	Excessive bleeding	Glaucoma
Hepatitis, (Supply Type in Details Below)	Kidney problems	Liver problems or Jaundice
Lung or breathing problems	Sinus trouble	Sleep Apnea
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
	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