Spectra Health Dental Clinic Patient Health History

Patient Health History

Spectra Health Dental Clinic
DISCLAIMER: The information contained in this form is for the sole use of Spectra Health as is appropriate under the HIPAA Privacy Rule.

The questions on this form are being asked in order to better serve you as a patient of Spectra Health.
Patient's Name:

First NameMiddle NameLast Name
patient name print
Preferred Name
Date of Birth

MonthDayYear
Phone Number
Format: (000) 000-0000.
Height
Weight
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurance Provider or Insurance Plan:
Email
example@example.com
Have you ever been hospitalized?
If yes, what for?
Which of the following conditions are you currently being treated or have been treated for in the past?
Cancer - Type
Diabetes - Last A1C
Hepatitis - Type
Pregnancy - Due Date
Sensory Disorder - Please explain your sensory disorder as concisely as possible:

0/50
Please list any past/current treatment or surgeries not listed above
If none please put N/A
Do you have any environmental, food or medication allergies?
If yes, please list and describe reaction as concisely as possible:

0/50
List any and all current medications AND the reason for them as concisely as possible:
If none please put N/A
Signed

Clear
Date

MonthDayYear
Date
ARCHIVED Patient's Name

First NameLast Name
Should be Empty: