Health History Form

West Park Dental

Michael E. Gallagher, DDS, FICD
Brian D. Gallagher, DMD

Patient Imformation

  • Today's Date
  • Who May We Thank for Referring You To Our Office?
  • Name
  • Spouse's Name
  • Address
  • Cleveland, State Zip
  • ,
  • Date of Birth
  • Social Security
  • Phone
  • Home- Work- Cell-
  • E-mail Address
  • How can we best contact you?
  • Cell PhoneHome PhoneTextWork PhoneE-mail
  • Employer
  • Occupation
  • In the event of an emergency, is there someone we should contact?
  • Name
  • Relationship
  • Phone
  • Home- Work- Cell-

Dental Insurance Information

Primary Insurance

  • Insurance Company Name
  • Phone
  • Group
  • Insurance Company Address
  • Policy Holder's Name (if different from above)
  • Policy Holder's SS or ID#
  • Policy Holder Date of Birth
  • Name of Employer
  • Please Provide Us With An Insurance Form or Coverage Card.
  • (Bring to the office)

Secondary Insurance (if applicable)

  • Insurance Company Name
  • Phone
  • Group
  • Insurance Company Address
  • Policy Holder's Name
  • Policy Holder's SS#
  • Policy Holder's SS or ID#
  • Policy Holder Date of Birth
PLEASE NOTE: Your signature is authorization for treatment and acceptance of responsibility of payment. In the case of minors, the person accompanying the minor is the responsible party.
Signed:
Past Due Balances - are charge interest of 1-1/2% per month on balances past due 90 days.

Dental History

  • Why have you come to the dentist today?
  • The date of your last dental visit:
  • Previous Dentist's Name
  • If you could wave a magic wand, and change anything about the appearance of you smile, what would you like to do?
  • Would you like to whiten your teeth?
  • YesNo
  • Do your gums bleed when you brush?
  • YesNo
  • Photo release: In exchange for good and valuable consideration, the receipt and adequacy of which is acknowledged the undersigned, together with his/her heirs and assigns, grants to Westpark Dental the right and license to display photographs of the undersigned to advertising and/or similar commercial and educational purpose. The undersigned understands and agrees that such photographs will be displayed to and be viewed by the patients, prospective patients, dental and office staff and other persons who may enter the office of the dentist.
  • Patient (parent / guardian if minor):
  • Date

Medical History

  • Your answers are for our records only will be considered confidential. Please note that during your initial visit you will be asked some questions about your response to this questionnaire and there may be additional questions concerning your health.
  • Physician's Name
  • Name of practice
  • Phone
  • Fax
  • Cleveland, State Zip
  • ,
  • Please list all medications you are currently taking:
  • Do you smoke?
  • YesNo
  • If yes, how much? Packs per day
  • Do you use smokeless tobacco products?
  • YesNo
  • My snoring affects other people
  • YesNo
  • I have used CPAP
  • YesNo
  • Blood Pressure
  • Date
  • Please check any of the following disease or medical problems you have been treated for.
  • Heart Conditions:
  • Congestive Heart Failure
    Heart Attack
    Heart Bypass Surgery
    Heart Valve Replacement
    High Blood Pressure
    Pacemaker
  • Other Conditions:
  •             Hepatitis:
  • ABC
  •             Diabetes:
  • Type IType II
  •                            
  • Asthma
    Emphysema
    Epilepsy
    Stroke
    Ulcers/Colitis
    HIV/AIDS
  • Cancer: Type
  • Artificial Joints: Type
  • Date
  • Please list any other medical conditions, recent surgeries, or hospitalizations not listed above:
  • Please list all medications you are currently taking:
  • Are you allergic to any of the following
  • AspirinCodeineErythromycin
    LatexPenicillinTetracycline
  • Please list any other drugs you are allergic to:

Please enter code above in the field below.