Adult Medical History Form

Adult Medical History Form
Patient Information
Today's Date

Month Day Year
Date
Patient's Name:

First Name Middle Name Last Name
I preferred to be called:
Address:

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Email
example@example.com
Home Phone
Please enter a valid phone number.
Cell Phone
Please enter a valid phone number.
Social Security No.:
Date of Birth

Month Day Year
Date
Age
Sex

Male Female
Occupation
Employer
Duration of Employment:
General Dentist:
Date of Last Visit:

Month Day Year
Date
Spouse:

First Name Middle Name Last Name
Phone No.
Please enter a valid phone number.
Address:

Same with me Different Address
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Marital Status
Occupation
Employer
Duration of Employment
Ex. 5 Years

Orthodontic Insurance Information
Primary Insurance
Insured Name:

First Name Middle Name (if applicable) Last Name
Relation:
Employer:
Date of Birth

Month Day Year
Date
Social Security No.:
Insurance Company:
Insurance Company Phone No.:
Please enter a valid phone number.
Member ID.:

Click here for Secondary Insurance
Secondary Insurance
Insured Name:

First Name Middle Name (if applicable) Last Name
Relation:
Employer:
Date of Birth

Month Day Year
Date
Social Security No.:
Insurance Company:
Insurance Company Phone No.:
Please enter a valid phone number.
Member ID.:

Emergency Information
Contact Person

First Name Last Name
Relation:
Phone Number
Please enter a valid phone number.