Medical History Form - Fresh Dental

Download a blank fillable Medical History Form - Fresh Dental in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Medical History Form - Fresh Dental with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

ADVERTISEMENT

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 Online
o Flyer / Mail
o Printed Ad
o Billboard
o Radio
o TV
o Community Event
o Health Fair / Screening
o Dr. Referral
o Driving / Walking by the Office
o Medicaid
o Insurance / Employer
o Friend / Relative
o Employee
o Other (Specify) ___________________________________________
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
o Yes
o No
Are you now seeing a physician?
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: _______________________________________________________________
o Actonel o Boniva o Fosamax
o Skelif
o Didrone
o Other _____________________
Have you or are you currently taking oral Bisphosphates?
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

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Medical
Go
Page of 2