Patient Medical History Questionnaire

Patient Information

First Name:

Last Name:

Date Of Birth:

Gender:

Physical Address:

Email Address:

P.O. Box:

Post Code:

Mobile Number:

Work Number:

Child Patient Information (under 18)

Parent/Guardian First Name:

Parent/Guardian Last Name:

Phone/Mobile:

Emergency Contact Information

Emergency Contact First Name:

Emergency Contact Last Name:

Tel Number:

Relationship:

Doctor Name:

Tel Number:

Country:

Health Insurance Information

Full Name Of Insured Party:

Relationship to Patient:

Insurance Company Name:

Group Number:

ID/Certificate Number:

Dental Coverage?

Important Medical Information

List all Medications that you currently take:

Please list ALL allergies:

Medical History

Seen by doctor in the past year?

Surgery or radiation therapy?

Blood pressure High or Low?

For Female Patients-Are you pregnant?

Yes

How Many Months?

Are you allergic to any medications?

Yes

List all medications your allergic to:

Regularly take aspirin or similar medication?

Yes

List all medication?

Do you currently have any dental issues?

Is there any other information about your medical or dental history, which may be important:

With this digital signature, I agree to be responsible for all charges relating to dental services and materials not paid by my dental benefit plan. I am also aware that if I miss a future appointment without giving 24 hrs notice I may be charged CI$100.00

Digital Signature First Name:

Digital Signature Last Name:

Date: