Patient Health History Form

Patient Name

Date

E-mail:

Patient's Birthdate

Family Dentist

Family Physician

Please check all that apply

Dental History

Yes

Medical History

Has patient had or have any of the following?

Yes

Please inform us if any changes occur to the patient's medical history.

Patient Information

* Date

Patient's Name

* Last Name

* First Name

* Middle Name

Address

* Street

* City

* State

* Zip

* Home Phone

* Birthdate

Social Security #

* If patient is a minor, give parent's or guardian's name

Whom may we thank for referring you to our office?

Responsible Party Information

Name

* Last Name

* First Name

* Middle Name

* Marital Status

Residence

* Street

* City

* State

* Zip

Mailing Address

* Street

* City

* State

* Zip

* How long at this address?

* Home Ownership? Rent Own Other

* Home Phone

* Work Phone

Previous Address (if less than 3 yrs.)

Street

City

State

Zip

* Social Security #

* Birthdate

* Relationship to Patient

* Employer

* Occupation

* No. Years Employed

Spouse's Name

* Last Name

* First Name

* Middle Name

* Relationship to Patient

* Employer

* Occupation

* No. Years Employed

* Social Security #

* Birthdate

* Work Phone

Insurance Information

Insured's Name

Insured's Soc. Sec. #

Insurance Company

Group No.

Local No.

Insurance Co. Address

Do you have dual Coverage? Yes No

If yes:

Insured's Name

Insured's Soc. Sec. #

Insurance Co.

Group No.

Local No.

Insurance Co. Address

Authorization - Assignment of Benefits

Emergency Information

* Name of nearest relative not living with you

* Complete Address

* Phone

I understand that where appropriate, credit bureau reports may be obtained.

* Signature (Parent's signature if minor)

Updated (date & initial)