Dental Medical History Form
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Confidential Dental and medical History Patient’s Name Age Date of Birth Address City, State, Zip Home Phone Cell Work Phone E-mail Best Contact: email Cell TexT Home Best Time to Reach You: SS Marital Status: SiNgle marrieD WiDoWeD DivorCeD Employer Employer Address Spouse’s Name Spouse’s Phone: (Work) (Cell) Emergency Contact Relation Emergency Phone Do you have dental insurance yeS No If YES, Insurance Carrier’s Name Group Phone Subscriber’s Name Relation to Patient Subscriber’s SS Subscriber’s Date of Birth Employer/Co.. Use of alcohol: n YES n NO n DAILY n WEEKLY n MONTHLY Use of recreational drugs: n YES n NO Do you use tobacco n YES n NO What type and how much per day CHECK ANY OF THE FOLLOWING WHICH YOU HAVE AT THE PRESENT OR HAVE HAD IN THE PAST: n n n n n n n n LOW BLOOD PRESSURE HIGH BLOOD PRESSURE HEART DISEASE / ATTACK ANGINA PECTORIS ARTIFICIAL HEART VALVE HEART FAILURE HEART PACEMAKER STROKE n n n n n n n n KIDNEY PROBLEMS SEXUALLY TRANSMITTED DISEASES ACID REFLUX ULCERS LIVER FAILURE HEPATITIS / JAUNDIC
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