Medical History Form

Full Name *

Date of birth

Phone *

Email *

Address *

City *

State *

Postal code *

Emergency Contact First Name *

Emergency Contact Last Name *

Emergency Contact Phone Number *

Emergency Contact Relation *

What is your gender? *

Male

Female

Do you have a Primary Care Physician and know their contact details? *

Yes

Primary Care Physician (PCP) Name

Primary Care Physician (PCP) Practice Name

Primary Care Physician (PCP) Phone Number

Have there been any changes in your general health in the last year? *

Yes

If yes, please specify

Do you have any bleeding/bruising problems, history of delayed healing, or recurrent infections? *

Yes

Are you experiencing any discomfort or pain in your facial or oral region? *

Yes

Do you experience pain when opening your jaw? *

Yes

Do you experience clicking noise when opening your jaw? *

Yes

Do you suffer from digestive problems? *

Yes

How long have these symptoms been present for? *

Do you consume alcohol?

No Alcohol Consumption

Casual Drinker

Regular Drinker

Alcoholic

Current Pharmacy Name *

Current Pharmacy City and Town *

I acknowledge that I have reviewed ALL questions/alerts on this questionnaire and responded accordingly. There are no other medical conditions or medications and/or allergies that have not been listed. I am aware that I must notify the practice of any future changes.

Patient Signature *

Clear