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Verardi Dental

Home
Scheduling
Procedures
Meet Our Team
More

Medical History

Medical History

Medical History Form

Medical History

Name: *

First Name

Last Name

Nick Name:

Email Address: *

Street: *

City: *

State: *

Zip Code: *

Cell Phone:

Country

(###)

###

####

Home Phone:

Country

(###)

###

####

Work Phone:

Country

(###)

###

####

Date of Birth: *

MM

DD

YYYY

Sex: *

Emergency Contact

First Name

Last Name

Emergency Contact Phone Number

Country

(###)

###

####

How were you referred to Verardi Dental:

Dental Insurance

Name of Insurance Company:

Insurance Phone Number:

Group Number:

Insurance ID or Social Security Number:

Employer Name:

Card Holder Name:

Card Holder Date of Birth:

MM

DD

YYYY

Your Dental History:

Date of Last Dental Visit:

MM

DD

YYYY

What was done at your last visit?

Previous Dentist's Name:

First Name

Last Name

Previous Dentist's Street:

Previous Dentist's City:

Previous Dentist's State:

Previous Dentist's Zip

Previous Dentist's Phone:

Country

(###)

###

####

Do you have any dental problems such as:

Do your gums bleed?

Yes

No

Check which appliance you currently wear:

I do not wear an appliance.

Dentures

Partials

Nightguard

Check which dental concern you currently have:

Grinding

Clenching

TMJ

Other

Your Medical History

The name & phone # of your physician:

Current medical condition?

List any and all medicine(s) including non-prescription, homeopathic or “Natural” remedies including diet pills?

Check all that apply to your current state:

Damaged heart valves, artificial valves, Congenital Heart defects

Bacterial Endocarditis

Pacemaker

Rheumatic Heart Disease

Heart trouble

Heart attack

Angina

Stroke

Arteriosclerosis

Prosthetic Joint Replacement

High / Low Blood Pressure

High / Low Cholesterol

Latex Sensitivity

Asthma or hay fever

Seizures, Epilepsy

Diabetes

Hepatitis

Liver Disease

Frequent or recurring mouth sores

Thyroid problems

Respiratory problems, emphysema, bronchitis

Arthritis

Stomach ulcer or hyperacidity

Kidney trouble

Tuberculosis

HIV / AIDS

Cancer

If Yes to any of the above, please explain and include the year:

Radiation treatment

Yes

No

If yes, body location

Do you have or have you had any disease, condition, or problem not listed?

Are you allergic to any medication?

Any other allergies (Please include: foods, such as eggs, metals, etc)

Check all that apply:

Do you smoke or use Tobacco

Do you drink alcohol?

Are you pregnant?

Are you taking birth control pills?

Thank you!

To provide our community with the highest standard of dental care. In providing this exceptional care, we plan to cultivate satisfied, appreciative, and prevention-oriented patients.

With quality care as our focus, we will strive to exceed our patient’s expectations with respect to customer service, friendliness and compassion.

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