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 AfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBruneiBulgariaBurkina FasoBurundiCôte d'IvoireCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCook IslandsCosta RicaCroatiaCubaCuracaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarReunionRomaniaRussiaRwandaSaint BarthelemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe 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 AfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBruneiBulgariaBurkina FasoBurundiCôte d'IvoireCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCook IslandsCosta RicaCroatiaCubaCuracaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarReunionRomaniaRussiaRwandaSaint BarthelemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe 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 signature keyboard 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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