Health History Form Email Date Last Name First Name Middle Name Phone Number Parent or Legal Guardian Emergency Contact Emergency contact Number Address City State Zip Occupation Employed By DOB SS Dental Information Reason for your dental visit today Date of last dental visit Medical Information Any chronic illness Allergies Smoke Taking any antiresortive agent for osteoporosis or Paget's disease Alendronate (Fosamax) Risedronate (Actonel) Intravenous Bisphosphonates Aredia or Zometa Taking any medication including vitamis Dental Insurance Subscriber Information Subscriber Name DOB Phone Number Insurance Company Insurance Co Phone Number Policy number Member ID Driver Licence Insurance Card