Oral and Maxillofacial Surgery

Main Header

Patient Information

Patient's Name

Nickname

Date of Birth/ Age

Social Security #

Sex

Male Female

Height

Weight

Patient's Address

Phone

Patient's Employer/ Occupation

Business Address

Patient's Email

Emergency Contact Information

Person not living with you whom we can contact in case of emergency/ Phone

Section Two

Who is your Family Physician

Address / Phone

Who is your Family Dentist

Address / Phone

Referred by

Address / Phone

Is This Visit Related To An Accident?

Auto

Yes No

Work Related

Yes No

Other

Date of injury

Insurance Co. handling this claim

Claim #

Name of Attorney/ Adjuster / Phone

Attorney/ Adjustor's Address

Confidential Information

Please describe your main symptom or problem (reason for today’s visit):

Date of last physical

Are you now, or have you been in the last five years, under the care of a physician for a specific problem

Yes No

If yes, describe

Medical History Continued

Is there any condition concerning your health about which the doctor should be told?

Yes No

Women

Are you Pregnant?

Yes No

If yes, delivery date?

If you might be pregnant, but are not sure, please check here:

☐

Are you Nursing?

Yes No

If yes, please know that anesthesia medicines are found in breast milk following an anesthetic and can sedate your child. You should use alternative methods for nourishment for you child for 24 hours after an anesthetic and should pump and discard your breast milk during that time.

Are you taking birth control pills?

Yes No

If yes, antibiotics that we prescribe may alter the effectiveness of birth control pills, such that you can get pregnant while taking the antibiotic. This possibility will be in effect for the remainder of your menstrual cycle. You should consult with your physician / OB-GYN for assistance regarding additional methods of birth control.

Please sign your initials to indicate your understanding

Signature

Click to Sign

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

MEDICATION LIST

Including those listed on the previous page, do you take any kind of medicine, drugs, diet supplements, herbal remedies, or pills?

Yes No

If no, please write “None” on the table below.
If yes, please list on the table below. See examples at the top of the table. Please fill in all information.

From what pharmacy do you obtain your prescription medicines?

If we prescribe medicine, do you prefer

Pills liquid

Name of Medicine

Date Started

Dose (mg)

Route
(Oral/IV/Topica/Nasal)

Frequency/ Directions on bottle

Reason for Taking

Example:
None

Example:
Metoprolol / Lopressor

01/01/2009

25 mg

Oral

Twice a day

Hypertension (high BP0

Example:
Gentamycine

01/01/2009

100 mg

Topical - Eyedrops

Once a day

Pinkeye

Please bring all of your medicine bottles to your appointment.

Signatures

I certify that I fully read and understand English, and I understand the questions and statements on this medical history form, and I have answered them truthfully.

My signature authorizes release of information to process my claim and to other health care providers about my history, examination, diagnosis, and treatment course.

Patient Signature

Click to Sign

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

Parent or Guardian (if minor or developmentally-delayed) or Language Interpreter Signature

Click to Sign

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

truForm by PBHS

Oral and Maxillofacial Surgery

Main Header

Demographic Information

Patient Information

Emergency Contact Information

Section Two

Who Is Responsible For The Account

Insurance Information

Patient Insurance Information

Primary Insurance Company

Secondary Insurance Company

Is This Visit Related To An Accident?

Medical History

Confidential Information

Past Medical History - Have you had or do you currently have (please check “Yes” or “No” to each question individually)

Past Surgical History

Medical History Continued

Family History

Women

Click to Sign

Allergies

Are you allergic to or have you had a reaction to any of the following medicines or substances? If yes, describe the reaction.

Medications

MEDICATIONS

MEDICATION LIST

Signatures

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Click to Sign

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Oral and Maxillofacial Surgery

Main Header

Demographic Information

Patient Information

Emergency Contact Information

Section Two

Who Is Responsible For The Account

Insurance Information

Patient Insurance Information

Primary Insurance Company

Secondary Insurance Company

Is This Visit Related To An Accident?

Medical History

Confidential Information

Past Medical History - Have you had or do you currently have (please check “Yes” or “No” to each question individually)

Past Surgical History

Medical History Continued

Family History

Women

Click to Sign

Allergies

Are you allergic to or have you had a reaction to any of the following medicines or substances? If yes, describe the reaction.

Medications

MEDICATIONS

MEDICATION LIST

Signatures

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.