Patient Registration And Medical History Form printable pdf download

PATIENT REGISTRATION AND MEDICAL HISTORY

(PLEASE PRINT)

Date____________________

Home Phone___________________________

Email Address________________________

Patient______________________________________________________________________________________________________

Last Name

First Name

Initial

Preferred Name

Street Address________________________________________City___________________State_____________Zip______________

Sex:

Age_______Birthdate________________

Single

Married

Widowed

Separated

Divorced

Employed by___________________________________________________Occupation_____________________________________

Business Address__________________________________________________Business Phone______________________________

Spouse Name___________________________________________________Spouse Birthdate_______________________________

Spouse Employed By_____________________________________________Occupation____________________________________

Business Address___________________________________________________Business Phone_____________________________

Who is responsible for this account?______________________________________Relationship to Patient_______________________

Social Security #___________________________________Spouse’s Social Security #______________________________________

Name of Dental Insurance Company___________________________________________Group Number_______________________

In case of emergency, who should be notified?__________________________________________Phone_______________________

Whom may we thank for referring you?____________________________________________________________________________

MEDICAL HISTORY

Physician’s Name___________________________________________________Date of Last Physical_________________________

Have you ever had any of the following? (check boxes that apply):

Heart Murmur

Headaches

Swollen Neck Glands

High Blood Pressure

Hepatitis, Jaundice or Liver Disease

Rheumatic Fever

Low Blood Pressure

Cancer

Sinus Problems

Circulatory Problems

Psychiatric Care

AIDS/HIV

Radiation Treatment

Mitral Valve Prolapse

Thyroid Disease

Artificial Heart Valves or Joints

Allergies to Anesthetics

Stroke

Recent Weight Loss

Allergies to Medicine or Drugs

Ulcer

Diabetes

Blood Disease

Venereal Disease

Respiratory Disease

Arthritis

Chemical Dependency

Epilepsy

Special Diet

Hemophilia

Do you have any drug allergies or have you ever had an adverse reaction to any medication?_____ If so, what____________________

___________________________________________________________________________________________________________

Have you ever responded adversely to medical or dental treatment?_____________________________________________________

Are you taking any medication at this time?________ If so, what________________________________________________________

Are you under the care of a physician? _________ For what conditions?_________________________________________________

(Woman) Do you suspect that you are pregnant?___________

Are you nursing?_______________

Are you happy with the appearance of your teeth?____________ If not, what bothers you:

Color

Shape

Position

Other___________________________________________________________________________________

Is there anything else we should know about your medical history?______________________________________________________

___________________________________________________________________________________________________________

The above information is accurate and complete to the best of my knowledge and is only for use in my treatment, billing and processing of insurance for

benefits for which I am entitled. I will not hold my dentist or any member of his staff responsible for any errors or omissions that I may have made in the

completion of this form.

__________________________

_____________________________________________________________

Date

Signature __