Mid-Peninsula Periodontics & Implant Center

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The Prevention-Based Center For Periodontal Specialty Care And Dental Implants

Confidential Health History Form

Prefix

Mr. Mrs. Ms. Dr.

Patient Name

Referring Doctor

Address

City / State / Zip

Date of Birth / Cell #

Home # / Work #

Spouse's Prefix

Mr. Mrs. Ms. Dr.

Spouse's Name / Date of Birth

This information will not be released unless specifically authorized by patient.

AIDS / HIV

Yes No

Anxiety

Yes No

Depression

Yes No

Treatment for emotional condition

Yes No

Women only (Please select Yes or No for each)

Are you or could you be pregnant? If YES, what month?

Yes No

Are you nursing?

Yes No

Are you taking birth control pills?

Yes No

All patients (Please select Yes or No for each)

Do you have or have you had any diseases other than diseases or medical problems NOT listed on this form?

Yes No

If YES, explain

Have you ever been premedicated for dental treatment?

Yes No

if YES, why

Have you ever taken Fen-Phen (a weight loss medication)?

Yes No

If Yes, when

Is there any issue or condition that you would like to discuss with the dentist in private?

Yes No

Insurance

We are happy to to submit your dental insurance claims if we have your complete information. Please provide us with the most current, accurate and complete information in order to expedite your reimbursement. If you have secondary insurance, please provide that separately.

Subscriber Name

Birth Date / Subscriber ID

Insurance Company / Group Number

Address

City / State / Zip

The practice of dentistry involves treating the whole person. If the dentist determines that there may be a potentially medically-compromised situation, medical consultation may be needed prior to commencement of dental treatment. I authorize the dentist to contact my physician.

Patient's Signature

Click to Sign

Date:-------------

Physician's Name / Date

Pharmacy

City / Cross streets

I certify that I have read and understand this form. To the vest of my knowledge, I have answered every question completely and accurately. I will inform my dentist of any changes in my health and/or medication. Further, I will not only hold my dentist, or any other member of his/her staff, responsible for any errors or omissions that I may have made in the completion of this form.

Signature of Patient (Parent or Guardian

Click to Sign

Date:-------------

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Mid-Peninsula Periodontics & Implant Center

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Patient Information

Confidential Health History Form

Select appropriate answer (leave blank if you do not understand the question)

Have you experiences any of the following? (please select Yes or No for each)

Have you had or do you have any of the following? (please select Yes or No for each)

This information will not be released unless specifically authorized by patient.

Are you allergic to or have you had a reaction to any of the following? (please select Yes or No for each)

Are you taking or have you taken any of the following in the last three months? (please select Yes or No for each)

Please list all medications you are currently taking

Women only (Please select Yes or No for each)

All patients (Please select Yes or No for each)

Insurance

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Mid-Peninsula Periodontics & Implant Center

Main Header

Patient Information

Confidential Health History Form

Select appropriate answer (leave blank if you do not understand the question)

Have you experiences any of the following? (please select Yes or No for each)

Have you had or do you have any of the following? (please select Yes or No for each)

This information will not be released unless specifically authorized by patient.

Are you allergic to or have you had a reaction to any of the following? (please select Yes or No for each)

Are you taking or have you taken any of the following in the last three months? (please select Yes or No for each)

Please list all medications you are currently taking

Women only (Please select Yes or No for each)

All patients (Please select Yes or No for each)

Insurance

Click to Sign

Click to Sign

PBHS truForm is best utilized in portrait mode.

Please rotate your device to portrait orientation to begin.

You are in Private Browsing mode.

This form requires that you disable private browsing to continue. Please open a new browser window and reload the form.

This form requires that you disable private browsing to continue.
Please open a new browser window and reload the form.