Medical History Form

Patient Name

Gender

Family Status

SS#:

Birth Date

Home Phone/Work Phone

Mobile Phone / Pager

E-mail

Address

Any changes to your dental insursnce?

Yes

Primary

Secondary

Have you ever had any of the following? Please answer Yes or No to each question by marking the boxes below.

Do you have any other health problems or conditions?

Yes

If yes, please explain

Are you taking any medications at this time?

Yes

If yes, please list

Have you been admitted to a hospital or needed emergency care during the past year?

Yes

If yes, please explain

Are you now under the care of a physician?

Yes

Name of Physician

Phone

Do you smoke?

Yes

Have you ever taken any diet drugs such as Phen-Phen, Redux, other?

Yes

Women: Are you pregnant now?

Yes

If yes, Due Date

Do you take any birth control medication?

Yes

To the best of my knowledge, all of the preceding answers and information provided are true and correct. If I ever have anychange in my health, I will inform the doctors at the next appointment without fail.

Reviewed the medical and Dental history directly with the Patient and hereby certify that I have read and understand the above. I acknowledge that my questions, if any about the above have been answered to my satisfaction, I will not hold my dentist or any other member of their staff, responsible for any errors or omission that I may have made in the completion of this form.