Complete Patient Information intake and medical history form Date: MM slash DD slash YYYY Patient is: Adult Child Patient informationTitle: Mrs. Ms. Mr. Dr. Name: First Middle Last Patient’s preferred name: Home address: Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Date of birth: MM slash DD slash YYYY Age:Gender Male Female Other Marital Status: Single Married Common-Law Telephone & Email:Preferred Contact: (In order for you to fill in the phone numbers, please check mark the preferred choice and a drop down box will appear. If you would like to include both phone numbers, click on both cellular and home phone. Cellular phone Home phone Preferred Contact: (In order for you to fill in the phone numbers, please check mark the preferred choice and a drop down box will appear. If you would like to include both phone numbers, click on both cellular and home phone. Cellular phone Home phone Cellular phone:Home phone:Email Please provide your email address for the purpose of communication and appointment reminders.Contact in case of emergency:Please notify (individual): Relationship to the patient: Cellular phone:Alternative phone number:COVID- 19 related questions:Have you had covid-19 before ? Yes No When? Have you received your 1st covid-19 vaccine? Yes No If so, when did you receive the vaccine? Brand type? Have you received your 2nd covid-19 vaccine( if applicable)? Yes No When? Brand type? Current Medical:Family Physician: Phone number of Physician:Medical conditions: (please list any current medical conditions that we should be made aware of)Are you taking any Medications? (please note there is room in the next questions to attach a list or photo of your medication list)(Please list all current medications you are taking including vitamins or supplements. Make sure to include the exact medication name, dosage, and what it is taken for)Please provide a pharmacy medications list or a written list by attaching below if you have one:Max. file size: 64 MB.Allergies:(if applicable)When was your last complete physical examination if known? ( please enter the exact date or details in months or years, i.e : 3 months ago) Do you consider yourself currently in good health? Yes No Medical HistoryPlease check YES or NO. If not sure, check NS To unclick a single box, click the box again and it will unclick. Are you currently under a specialist's care or have you been under a specialist's care in the past 2 years? Yes No Please provide details below if the above question is applicable: Have you been hospitalized in the past two years? Yes No If yes, why? Have you had any type of surgery in your lifetime? Yes No Please list details if the answer is yes: When walking, do you ever have to stop because of pain in your chest or shortness of breath? Yes No Are you on a prescription diet? Yes No Have you ever been diagnosed as having a tumor or cancer? Yes No Please elaborate with details and dates if the answer above is yes: Do you experience problems with healing? Yes No Do you wish to speak privately with the doctor about any problem? Yes No If the answer is yes, please explain below: Are you a smoker of any kind? If yes, how much? how often? please explain Yes No Please provide details below if applicable: Do you bruise easily or bleed excessively? Yes No Have you ever been warned about anesthetic risks? Yes No Have you been told that you need to pre-medicate with antibiotics prior to your dental visit? Yes No If the answer is yes, what have you been prescribed, and what condition do you have that would need pre-medication? Have you ever experienced or currently have the following?Stomach Intestinal Problems YES NO Transdermal Nicotine Patches YES NO High Blood Pressure Hypertension YES NO Low Blood Pressure YES NO Heart Failure YES NO Congenital Heart Lesion YES NO Articial Heart Valve YES NO Heart Pacemaker YES NO Heart Surgery YES NO Heart Murmur YES NO Mitral Valve Prolapse YES NO Chest Pain YES NO Angina pectoris YES NO Shortness of Breath YES NO Stroke YES NO Anemia YES NO Kidney Trouble YES NO Ulcers YES NO Asthma YES NO Sinus Trouble YES NO Frequent Cough YES NO Lung Disease YES NO Tuberculosis YES NO Liver Disease YES NO Hepatitis A (infec.) YES NO Hepatitis B (serum) YES NO Hepatitis C YES NO Thyroid Disease YES NO X-Ray/Cobalt Treatment YES NO Cardiac Arrest/ Heart Attack YES NO Head/Neck Injuries YES NO Fainting or Dizziness YES NO Artificial Joints/Hips YES NO Diabetes or Hypoglycemia YES NO Arthritis Rheumatism YES NO Epilepsy or Seizures YES NO AIDS(HIV Positive) YES NO Venereal Disease YES NO Herpes YES NO Cold Sores YES NO Blood Disorders YES NO Circulation Problems YES NO Hemophilia YES NO Cancer YES NO Chemotherapy/Radiation YES NO Mental or nervous disorders YES NO Been under psychiatric care? YES NO Drug or alcohol addiction? YES NO If you answered yes to any of the above questions in this section, please elaborate below: Women only sectionAre you pregnant? YES NO Are you taking birth control pills? YES NO Are you nursing? YES NO Are you taking fertility drugs? YES NO Additional Important medical informationIf there is anything further you would like to mention regarding your health that you feel you need to explain that you think is important that we should know? YES NO If the answer is yes, please list details below:ReferralsHow did you hear about our office? Social media Google My Physician A staff member of the office I Live In the neighborhood A Patient from the office Other referral choice not listed here: If referred by a patient in our office, what is the name of the referring patient? If you heard about our office through another source not mentioned above, please list details below:Do you have Dental Insurance Coverage? YES NO If the answer is yes, please list the name of the Insurance Company: Policy holder’s full name if it is not the patient: Policy Holder’s Date of Birth: MM slash DD slash YYYY Policy (Group or plan contract) number (if not sure please attach a picture as instructed) : Certificate (Identification) number(if not sure please attach a picture as instructed below): If you have a picture of the insurance card or a screenshot of the insurance information, please attach here:Max. file size: 64 MB. Attestation I attest that the above medical information is true and completed to the best of my ability. I understand that by disclosing all of my medical information to my dentist or dental hygienist, that it is in my best interest to do so medically. Name Full Name Date MM slash DD slash YYYY Once fully read and reviewed, please make sure that the above document is filled out appropriately. By signing below and submitting this document, we are assuming that it has been read in its entirety. All patient signatures will be verified for authenticity in the office. Signature
