Medical History Form Name * First Name Last Name Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Email * Date of Birth * MM DD YYYY Best Number To Contact You * Cell Phone Number (###) ### #### Emergency Contact Name And Number * What is your marital status? * Single Married Common Law Divorced Widowed How Did You Hear About Us? * Google Instagram Website Referral Other If you were referred to us, who referred you? Do You Have Dental Insurance? * If yes, please specify insurance details in next questions. In the event that your spouse has their own insurance, please bring both cards to the appointment. Yes No Yes, and my spouse has separate insurance as well Insurance Company Please Specify Your Insurance Company and The Insurance Company of Your Spouse if Applicable Employee Name Employee Name and Name of Spouse if They Hold Their Own Separate Insurance Employee Date of Birth MM DD YYYY Employer Your Employer Name and the Name of Your Spouse's Employer if Applicable Group Number Your Group Number and the Group Number of Your Spouse's Insurance if Applicable ID or Certificate Number Your Certificate Number and That of Your Spouse's Insurance if Applicable Insurance EDI Submission Acknowledgement I give Dr. Aurora Moldovan authorization to send my family's dental claims electronically Physician Name And Number * Pharmacy Name And Number * Are you currently taking any medications? * Yes No If you are taking any medications, please list them: Are you fully vaccinated against COVID-19? * This is solely to keep your medical and drug history up to date. Yes No Prefer Not to Answer Are you allergic to or have you reacted adversely to any of the following? Aspirin Penicillin Tetracycline Erythromycin Other Antibiotics Codeine or Other Narcotics Sedatives or Sleeping Pills Local Anesthetics Other None of the Above If you answered Other on the previous question, please specify. Do you have or have you had any of the following conditions? * Check all that apply. High Blood Pressure Heart Trouble Mitral Valve Prolapse Angina Pectoris Heart Murmur Artificial Heart Valve Heart Surgery Heart Attack Artificial Joint Stomach Ulcer Sleep Apnea Stroke Glaucoma Liver Disease Anemia Hepatitis A/B/C Excessive Bruising Yellow Jaundice Thyroid Disease Leukemia Hemophilia or Blood Transfusion Kidney Trouble HIV (AIDS) Venereal Disease Cold Sores Emphysema/Bronchitis Persistent Cough Asthma Tuberculosis Drug Addiction Alcohol Dependency Hayfever Sinus Troubles Fainting Eating Disorder Psychiatric Treatment Diabetes or Excessive Thirst Arthritis Osteoperosis Cancer Epilepsy/Seizures Rheumatic or Scarlet Fever None of the Above When you walk up stairs or take a walk, do you ever have to stop because of pain in your chest? * Yes No Do your ankles swell during the day? * Yes No Do you use more than 2 pillows to sleep? * Yes No Have you ever experienced problems with healing? * Yes No Do you ever wake up from sleep short of breath? * Yes No Are you on a special diet? * Yes No Has your medical doctor ever said you have cancer or a tumor? * Yes No Do you have any disease, condition, or problem not listed? * Yes No If you answered "Yes" to the previous question, please specify. Consenting Signature * By entering your name here, you consent that the above information is correct to your knowledge. Date * MM DD YYYY Thank you!
