WelcomeWelcome to Apolonia Dental ! Thank you for choosing our dental practice. Medical History Form All information is private and confidential First Name: Last Name: Date of Birth: Address: City: Postal Code: Telephone Numbers: Home: Work: Cell: Email: Can we contact you via email? YesNo Emergency Contact Name: Tel#: Physician: Occupation: Employer: Do you have dental insurance? YesNo Group/Plan #: Member/ID #: Subscribers Name: Date of Birth: Have you been hospitalized or had any operations? YesNo Do you have any drug allergies? YesNo Are you currently taking any medications, or nonprescription drugs/supplements? YesNo Have you or your relatives had problems with sedation or anesthesia, including Malignant Hyperthermia? YesNo Any other allergies (e.g. Latex, Eggs, Metal, Hay Fever)? YesNo Are you a smoker? YesNo Please indicate if you have a history of the following: Heart problems YesNo High/Low Blood Pressure/Stroke YesNo Diabetes or Hypoglycemia YesNo Asthma, Persistent cough, Tuberculosis YesNo Kidney or Thyroid disorders YesNo Hepatitis, Jaundice or Liver problems YesNo Kidney or Thyroid disorders YesNo Bleeding disorder or Anemia YesNo Fainting, dizziness, nervous disorders YesNo Epilepsy, Seizures or Convulsions YesNo Conditions that could affect your immune system (e.g. AIDS, HIV, Leukemia) YesNo Women: Are you pregnant or nursing? YesNo Are you having a dental problem we can help with today? Are you happy with your smile? Who can we thank for referring you to the Apolonia Dental? I consent to the collection, use and disclosure of my personal information YesNo Attach a Photo ID: DL, PR Card, Passport, Other Government ID Upload a fileNo File Chosen Signature (Initials)
