ABC Dental – Patient History Form

'Please email' Section

Please email or fax your medical insurance card (front and back) to us in advance of your appointment: info@abcdentalcom Fax: (555) 555-5555

Please fill in the form below and submit.

Please also complete our COVID-19 Questionaire and our Dentalmap Form

Please complete the information below and submit the form online or, if you prefer, print out the form after full or partial completion and bring it when you come to our office. This form contains confidential information and is delivered to your dentist through a secure Internet connection.

Patient Information Header

Patient Information

Name Section

Name

First *

Middle

Last *

Address Section

Address

Street Address *

Address Line 2

City *

State

ZIP / Postal Code *

Country

Contact Information Group

Contact Information

Home or Cell *

Alternate Phone (Optional)

Work (Optional)

Email Address

Other Information Group

Other Information

Employer

Occupation

SSN (last 4 digits only!) *0 / 4

Race / Ethnicity

GenderFemaleMale

Preferred Language

Who may we thank for referring you to our office?

Name of Medical Doctor

Doctor's Phone Number

Date of Last Eye Exam

Current Height

Current Weight

Spouse or Guardian (If Applicable)

Medical History Group

Medical History

Do you have any allergies to medications?NoYes

If Yes, list medication(s) and reaction below:

List any other medication you take including oral contraceptives, aspirin, OTC medicines, etc.:Include medication name, dosage, and frequency taken

List all major injuries, surgeries and/or hospitalizations you have had:

If other eye disorders, please explain:

Are you pregnant or nursing?NoYes

Do you wear glasses?NoYes

If Yes, how old is your current pair of glasses?

Do you wear contact lenses?NoYes

If Yes, how old is your current pair of lenses?

Family History Section

Family History

If Yes to any of the above, please explain:

If Other, please explain:

I prefer to discuss my Social History Information directly with my doctor.Yes

Do you drive?NoYes

If Yes, do you have visual difficulty when driving?NoYes

If Yes, please describe:

Do you use tobacco products?NoYes

If Yes, list type/amount/how long:

One Third Spacer

Do you drink alcohol?NoYes

If Yes, list type/amount/how long:

One Third Spacer

Do you use illegal drugs?NoYes

If Yes, list type/amount/how long:

One Third Spacer

Have you ever been exposed to or infected with:GonorrheaHepatitisHIVSyphillis

REVIEW OF SYSTEMS

Do you currently or have you ever had any problems in the following areas?

Constitutional Section

Fever, Weight Loss/GainNoYes

Integumentary (Skin)NoYes

One Third Spacer

Neurological Section

Neurological

Eyes Section

Eyes

Endocrine Section

Endocrine

Ears, Nose, Mouth, Throat Section

Ears, Nose, Mouth, Throat

Respiratory Section

Respiratory

Gastrointestinal Section

Gastrointestinal

DiarrheaNoYes

ConstipationNoYes

One Third Spacer

Genitourinary Section

Genitourinary

Genitals/Kidney/BladderNoYes

Bones/Joints/Muscles Section

Bones/Joints/Muscles

Lymphatic/HematologicSection

Lymphatic/Hematologic

AnemiaNoYes

Bleeding ProblemsNoYes

One Third Spacer

Allergic/Immunologic Section

Allergic/Immunologic

Allergic/ImmunologicNoYes

Psychiatric Section

Psychiatric

PsychiatricNoYes

If you answered Yes to any of the above or have a condition not listed, please explain and list medications:

Patient Signature

Date

Text