Kelly A. Barnes, D.M.D.           Joyce Johnston-Neeser, D.M.D
 

11 Boston Post Road, Suite 215 - Sudbury, Massachusetts 01776 - Tel: 978-443-7101 Fax: 978-443-7915

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MEDICAL HISTORY FORM
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Referred by
General Dentist
Date
 
 
PATIENT INFORMATION:
  Title
  First Name
  Last Name
  Preferred Name
  Street Address
  City
  State
  Zip
  Home Phone
  Business Phone
  Cell Phone
  Email
  Sex
  Date of Birth
  SS#
  Occupation
 Person to Contact in case of         Emergency
 Relationship & Phone #
 
IS SOMEONE ELSE RESPONSIBLE FOR PAYMENT OF THE ACCOUNT?
If so, please complete the following:
  Title
  First Name
  Last Name
  Street Address
  City/State/Zip
  Home Phone
  Cell Phone
  Business Phone
 

 DO YOU HAVE DENTAL       INSURANCE?

       If Yes, complete the following:
  Insurance Company
  Primary Subscriber Name
  Relationship to Patient
  Date of Birth
  Employer
  ID#
  Group or Plan Number
  Secondary Subscriber Name
  Relationship to Patient
  Date of Birth
  Employer
  ID#
 Group or Plan Number
 
 Name, Address, Phone # of Physician
Are you now or have you recently been under the care of a Physician?
For what have you recently been hospitalized?
Do you have a serious illness?
 
Do you have any allergies or adverse reactions to any of the following medications?
Please check appropriate answers.

 
penicillin     nsaids(ibuprofen, Motrin, Advil)    
latex        
aspirin     local anesthesia    
Are you currently taking oral contraceptives?    
Are you curently taking any medications?    
Do you have any bleeding problems?    
Are you pregnant or nursing?    
Have you in the past or are you presently being treated for any infectious diseases?    
 
PLEASE INDICATE BY CHECKING THE APPROPRIATE BOX IF ANY OF THE FOLLOWING PERTAIN TO YOU IN ANY WAY, PAST OR PRESENT:  PLEASE CHECK YES OR NO.
  Rheumatic Fever                 Artificial joint/valve               High blood pressure      
  Anemia                            Nervous condition                Ulcers                           
  Stroke                                  Recreational drug use        Kidney disease             
  Asthma                                Hepatitis/liver disorder        Colitis                           
  Seizures                              Tuberculosis                        Sinusitis                        
  Thyroid Treatment               Psychiatric care                  

Sexually transmitted     
disease        

  Diabetes                              AIDS/ARC/HIV positive    Blood transfusion          
  Hepatitis                              Chemotherapy                    Blood disease               
  Afthritis                                Heart problems                  Radiation therapy         
  Hip Replacement Heart murmur                     Organ transplant          
  Knee Replacement              Mitral valve prolapse           
 
  Other
Patient Signature Date
 Reviewed by:
Date