Health History Health History Patient Information Record Pt. Chart # Patient First Name: * First Patient Middle Initial: Patient Last Name: * Last Date of Birth: Age: Gender Male Female Marital Status: Yes No Address Address Address Address City City State/Province State/Province Zip/Postal Zip/Postal Country Afghanistan Aland Islands Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bonaire, Sint Eustatius and Saba Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Bulgaria Burkina Faso Burundi Côte d'Ivoire Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Croatia Cuba Curacao Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Malvinas) Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Holy See Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea Northern Mariana Islands Norway Oman Pakistan Palau Palestine Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Reunion Romania Russia Rwanda Saint Barthelemy Saint Helena, Ascension and Tristan da Cunha Saint Kitts and Nevis Saint Lucia Saint Martin (French part) Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Sint Maarten (Dutch part) Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands South Korea South Sudan Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Virgin Islands, British Virgin Islands, U.S. Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe Country Home Phone: Work Phone: Cell Phone Social Security #: Email: Authorization to receive text: Yes No Authorization to receive email: Yes No Insurance Information Policy Holder: Patient Spouse Parent Employed By: Occupation: Address Address Address Address City City State/Province State/Province Zip/Postal Zip/Postal Country Afghanistan Aland Islands Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bonaire, Sint Eustatius and Saba Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Bulgaria Burkina Faso Burundi Côte d'Ivoire Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Croatia Cuba Curacao Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Malvinas) Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Holy See Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea Northern Mariana Islands Norway Oman Pakistan Palau Palestine Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Reunion Romania Russia Rwanda Saint Barthelemy Saint Helena, Ascension and Tristan da Cunha Saint Kitts and Nevis Saint Lucia Saint Martin (French part) Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Sint Maarten (Dutch part) Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands South Korea South Sudan Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Virgin Islands, British Virgin Islands, U.S. Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe Country Payment is due at time of service if insurance section is not completed: PRIMARY Dental Insurance: ID/SS #: Policy Holder: DOB: Group #: SECONDARY Dental: ID/SS #: Policy Holder: DOB: Group #: PRIMARY Medical Insurance: ID/SS #: Policy Holder: DOB: Group #: SECONDARY Medical: ID/SS #: Policy Holder: DOB: Group #: Name of Parent or Guardian if Patient is a Minor: Patient Referred By: (Required) Name of General Dentist: Name of Regular Physician: Phone: Pharmacy of Choice Medical History Are you now or have you been under the care of a physician during the past 5 years? Yes No If YES, please explain: If YES, please explain: Do you take any medications regularly? Yes No Are you taking any now? Yes No If YES, please list Medications: * Dosage: *** Have you ever had any surgeries or hospitalizations? Yes No If yes please list surgeries and hospitalizationsIf yes please list surgeries and hospitalizations Have you ever had breathing difficulty such as asthma, emphysema, chronic cough, pneumonia, tuberculosis, or any other lung disorder? Yes No Do you smoke? Yes No Check any of the following which you have or had in the past: Heart Failure Heart disease or attack Angina Pectoris High Blood Pressure Heart Murmur Rheumatic Fever Congenital Heart Lesions Scarlet Fever Artificial Heart Valve Heart Pacemaker Heart Surgery Spells Artificial Joint Anemia Stroke Kidney Trouble Ulcers Emphysema Cough Tuberculosis Asthma Hay Fever Sinus Trouble Allergies or Hives Diabetes Thyroid Disease x-ray or Cobalt x-ray Chemotherapy Arthritis Rheumatism Cortisone Medication Glaucoma Pain in Jaw Joints Hepatitis A (infectious) Hepatitis B (serum) Liver Disease Jaundice Blood Transfusion Drug Addiction Hemophilia Venereal Disease Genital Herpes Epilepsy or Seizures Fainting or Dizzy Psychiatric Treatment Sickle Cell Disease Bruise Easily Latex Allergy HIV/AIDS Are you allergic to ANY medications? Yes No If YES, whatIf YES, what Have you ever had undesirable effects from taking these drugs? General Anesthetics Local Anesthetics Pain Killers Cortisone Tranquilizers Antibiotics Sedatives Stimulants Sleeping Pills Mouth Wash Do you have popping or clicking in your jaw? Yes No Have you had TMJ problems in the past? Yes No Do you bleed easily or for long periods? Yes No Do you now have a cold, cough or sinus trouble? Yes No Do you wear contact lenses? Yes No If female…are you pregnant? Yes No When you walk up stairs or exercise, do you ever experience chest pain or shortness of breath or have to stop simply because you are very tired? Yes No Do your ankles swell during the day? Yes No Do you use more than 2 pillows to sleep? Yes No Do you have any disease, problem, or condition not listed above? Yes No Do you have any food allergies? Yes No If yes, please listIf yes, please list To the best of my knowledge, all of the preceding answers are true and correct. If I ever have any change in my medical history (including changes in medicine) or health, I will inform the doctor of dentistry at my next appointment. Yes No Date Signature Clear Electronic Disclosure, Electronic Signature and Electronic Statements Agreement Please read this Electronic Records Disclosure and Agreement carefully: By checking the boxes on the website for patient forms, AND, by typing your name in the e-sign box here, you consent to the electronic delivery of the disclosures, information you provided, terms and conditions and any other documents to be included in your electronic and paper copy records. You also agree that we do not need to provide you with additional paper (non-electronic) copies of the disclosures, agreements, change notices, terms and conditions and any other documents, unless specifically requested. 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