Medical History Form
Highlighted questions must be completed

Welcome to Smiles by Holsinger & Higgins
Having a great smile goes far beyond cosmetics. In this sometimes-critical world, a beautiful smile makes a powerful first impression.  A smile is a symbol of overall health and well-being; it allows us to feel better about ourselves. We can help you create the smile you've always wanted.

PATIENT INFORMATION (Confidential)
Title:
Name:
How would you like
to be addressed?
Mail delivered to: Self Other
If other, list:
Address:
City:
State:
Zip:
Home Phone: ex. 410-479-1234
Work Phone: ex.410-479-1234
Cell Phone: ex. 410-479-1234
Daytime Contact Phone:
Email Address:
Birth Date:
Sex: Male    Female
Marital Status:
SSN: (Your SSN will be required at the front desk)
Employer:
Employer Address:
Employer City:
Employer State:
Employer Zip:
Person to contact in case of emergency
Emergency phone:
How did you hear about us?
Whom may we thank for referring you?
Confidential Responsible Party Information
Name:
Marital Status:
Address:
City:
State:
Zip:
How long at this address:
Previous address  
(if less than 3 yrs.):
Home Phone: ex. 410-479-1234
Work Phone: ex. 410-479-1234
SSN: (Your SSN will be required at the front desk)
Birth Date:
Relationship to Patient:
Employer:
Occupation:
No. Years Employed:
Spouse's Name:
Relationship to Patient:
Employer:
Occupation:
No. Years Employed:
SSN: (Your SSN will be required at the front desk)
Birth Date:
Work Phone:
PATIENT MEDICAL HISTORY
Physician
Office Phone ex. 410-479-1234
Last Exam Date
1. Are you under physician's care now? Yes No
2. Have you ever been hospitalized or had a major operation? Yes No
3. Have you ever had a serious head or neck injury? Yes No
4. Are you taking any medications including non-prescription medicine and herbal medicines and supplements? Yes No
If yes,
Please list medication or supplement, dosage and when taken:
Medication/Supplement - Dosage - When Taken













5. Do you take, or have you taken, Phen-Fen or Redux? Yes No
6. Are you on a special diet? Yes No
7. Do you use tobacco? Yes No
8. Do you use controlled substances? Yes No
9. Do you have any hearing difficulties? Yes No
10. Women Only, are you:
Pregnant or
Trying to get pregnant ?
Yes No
Taking oral contraceptives? Yes No
Are you nursing? Yes No
11. Are you allergic to or have any reactions to the following?
Aspirin Yes No
Penicillin or other antibiotics Yes No
Codeine Yes No
Acrylic Yes No
Metal Yes No
Latex Yes No
Local Anesthetics
(i.e. Novocaine)
Yes No
Other (list)
If Yes,
please explain
10. Do you have or have you had any of the following?
AIDS or HIV Infection Yes No
Alzheimer's Disease Yes No
Anaphylaxis Yes No
Arthritis/Gout Yes No
Anemia Yes No
Angina Yes No
Artificial Heart Valve Yes No
Artificial Joint Yes No
Asthma Yes No
Blood Disease Yes No
Blood Transfusion Yes No
Breathing Problem Yes No
Bruise Easily Yes No
Cancer Yes No
Chemotherapy Yes No
Chest Pains Yes No
Cold Sores/Fever Blisters Yes No
Congenital Heart Disorder Yes No
Convulsions Yes No
Cortisone Medicine Yes No
Diabetes Yes No
Drug Addiction Yes No
Easily Winded Yes No
Emphysema Yes No
Epilepsy or Seizures Yes No
Excessive Bleeding Yes No
Excessive Thirst Yes No
Fainting Spells or Dizziness Yes No
Frequent Cough Yes No
Frequent Diarrhea Yes No
Frequent Headaches Yes No
Genital Herpes Yes No
Glaucoma Yes No
Hay Fever Yes No
Heart Attack/Failure Yes No
Heart Murmur Yes No
Heart Pace Maker Yes No
Heart Trouble or Disease Yes No
Hemophilia Yes No
Hepatitis A Yes No
Hepatitis B or C Yes No
Herpes Yes No
High Blood Pressure Yes No
Hives or Rash Yes No
Hypoglycemia Yes No
Irregular Heartbeat Yes No
Joint Replacement Yes No
Kidney Problems Yes No
Leukemia Yes No
Liver Disease Yes No
Low Blood Pressure Yes No
Lung Disease Yes No
Mitral Valve Prolapse Yes No
Pain in Jaw Joints Yes No
Parathyroid Disease Yes No
Psychiatric Care Yes No
Radiation Treatments Yes No
Recent Weight Loss Yes No
Recent Dialysis Yes No
Rheumatic Fever Yes No
Rheumatism Yes No
Scarlet Fever Yes No
Shingles Yes No
Sickle Cell Disease Yes No
Sinus Trouble Yes No
Spina Bifida Yes No
Stomach / Intestinal Disease Yes No
Stroke Yes No
Swollen Limbs Yes No
Thyroid Disease Yes No
Tonsillitis Yes No
Tuberculosis Yes No
Tumors or Growth Yes No
Ulcers Yes No
Venereal Disease Yes No
Yellow Jaundice Yes No
PATIENT DENTAL HISTORY
1. Do your gums bleed while brushing or flossing? Yes No
2. Are your teeth sensitive to hot, cold, or sweets? Yes No
3. Do you feel pain in any teeth? Yes No
4. Do you have any sores or lumps in your mouth? Yes No
5. Have you had any head, neck, or jaw injuries? Yes No
6. Has your jaw ever given you problems with:
Clicking Yes No
Pain Yes No
Opening or Closing? Yes No
Chewing? Yes No
7. Do you clench or grind your teeth? Yes No
8. Have you ever had braces or orthodontics? Yes No
9. Have you ever had excessive or prolonged bleeding after an extraction? Yes No
10. How many headaches do you get per week?
11. How many days per week do you wake up and feel that you can take on the world?
12. Do your feet hurt when you stand? Yes No
13. Please rate your smile from 1 - 10 with 10 being the greatest smile you can imagine:
14. Are you hearing impaired? Yes No
AUTHORIZATION AND RELEASE

I certify that I have read and answered the above questions accurately. I understand that providing incorrect information can be dangerous to my health. I authorize Dr. Holsinger and Dr. Higgins to release any information, including the diagnosis and the records of any treatment or examination rendered to me during the period of such Dental Care, to the third party payers and/or health practitioners. I consent to photography and videos done for the purpose of training, press releases, articles, printed marketing pieces, advertising and other possible means of marketing. I will not hold Smiles by Holsinger & Higgins or its assignees responsible for errors or omission in said marketing. I grant all rights and use of my photographs to Smiles by Holsinger & Higgins and their assignees without expectations of compensation of any kind. I agree to be responsible for payments of all services rendered on my behalf or my dependents on day of service. Any balance over 30 days will be subject to a 1.5% finance charge per month with a minimum fee of $2.00.