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Includes an emergency contact and pharmacy section. Medical history section gathers current medical care, prior hospitalizations, injuries, medications and drug history, special diet, tobacco and controlled substances, and extensive medical conditions with allergy and yes/no prompts. Concludes with patient/guardian acknowledgement, signature and date, and an authorization to release identifying health information with defined scope and recipients.",{"@graph":63,"@context":123},[64,80,102],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/patient-registration-forms-medical-history-and-authorization-for-release-of-health-information/281895/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/patient-registration-forms-medical-history-and-authorization-for-release-of-health-information/281895.png","ImageObject",442,249,{"name":88,"@type":89},"Xiajie","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-27","2026-09-16",true,{"@type":98,"interactionType":99,"userInteractionCount":101},"InteractionCounter",{"@type":100},"ViewAction",20,{"@type":103,"mainEntity":104},"FAQPage",[105,111,115,119],{"name":106,"@type":107,"acceptedAnswer":108},"What information is required in the patient information section?","Question",{"text":109,"@type":110},"It requests patient identification and contact details such as date of birth, first/middle/last name, preferred name, address, city/state/zip, primary and secondary phone numbers, email, and sex.","Answer",{"name":112,"@type":107,"acceptedAnswer":113},"What topics are covered in the medical history questions?",{"text":114,"@type":110},"The form asks about physician care, past hospitalizations and major operations, serious head/neck injuries, current medications and drug history (including specific drug classes), special diet, tobacco use, controlled substances, and allergies.",{"name":116,"@type":107,"acceptedAnswer":117},"How does the form handle responsible party details?",{"text":118,"@type":110},"If the responsible party is not the patient, it collects the responsible party’s relation to the patient, date of birth, name, address, city/state/zip, phone numbers, and identification details.",{"name":120,"@type":107,"acceptedAnswer":121},"What does the authorization for release of identifying health information include?",{"text":122,"@type":110},"It authorizes the dental office to release health information under specified terms, including a detailed description of records to be released and the recipients who may receive the information.","https://schema.org",{"og:url":78,"og:type":125,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":127,"canonical":78},"index,follow",{"doc_id":129,"site_id":56},281895,1791379063,{"code":4,"msg":5,"data":132},{"doc_id":129,"user_id":133,"nickname":88,"user_avatar":134,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":135,"file_id":136,"file_url":137,"file_type":138,"file_size":139,"view_count":101,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":140,"language":141,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":142,"faqs":143,"seo_title":144,"seo_description":61,"update_tm":145,"read_time":73,"preview_page_count":4},8814010472675,"https://avatar.qwps.com/avatar/WGlhamll","PATIENT REGISTRATION  \nPatient Information:  \nDate ofBirth:    \nFirst Name:   Middle Initial:    \nLast Name:   Preferred Name:   Address:   Address 2:    \nCity, State, Zip:   Primary Phone:   ○ Cell ○ Home. ○ Work Secondary Phone:   ○ Cell ○ Home. ○ Work  \nE-mail:   Sex: ○ Female ○ Male Marital Status: ○ Married ○ Single ○ Divorced ○ Separated ○ Widowed Social Security \\#:   Drivers Lic\\#:    \nResponsible Party:  \n( If not the patient, person financially responsible for them. Usually the owner of the insurance policy. )  \nRelation to Patient:   Date ofBirth:    \nFirst Name:   Middle Initial:    \nLast Name:   Preferred Name:   Address:   Address 2:   City, State, Zip:    \nPrimary Phone:   ○ Cell ○ Home. ○ Work Secondary Phone:   ○ Cell ○ Home. ○ Work Social Security \\#:   Drivers Lic\\#:    \nEmergency Contact:  \nFirst Name:   Last Name:   Phone Number:    \nPharmacy:  \nName of Pharmacy:   Phone Number:   Address:   Adress 2:   City, State, Zip:    \nTIME 10:43 AM DATE 7/12/2011  \nMEDICAL HISTORY  \nPATIENT NAME   Birth Date    \nAlthough dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions.  \nAre you under a physician's care now? Have you ever been hospitalized or had a major operation?  \nHave you ever had a serious head or neck injury? Are you taking any medications, pills, or drugs? Do you take, or have you taken, Phen-Fen or Redux? Have you ever taken Fosamax, Boniva, Actonel or anyother medications containing bisphosphonates?  \nAre you on a special diet?  \nDo you use tobacco? Do you use controlled substances?  \nIf yes, please explain:    \nIf yes, please explain:    \nIf yes, please explain:    \nIf yes, please explain:    \n~~   ~~ Women: Are you  \nPregnant/Trying to get pregnant?  Yes  No Taking oral contraceptives?  Yes  No Nursing?  Yes  No  \nAspirin  Penicillin  Codeine  Local Anesthetics  Acrylic  Metal  Latex  Sulfa drugs  \n Other If yes, please explain:    \nAre you allergic to any of the following?  \n\n| ~~   ~~ Do you have, or have you had, any of the following? ~~   ~~ |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- |\n| AIDS/HIV Positive  Yes\u003Cbr>Alzheimer's Disease  Yes\u003Cbr>Anaphylaxis  Yes\u003Cbr>Anemia  Yes\u003Cbr>Angina  Yes\u003Cbr>Arthritis/Gout  Yes\u003Cbr>Artificial Heart Valve  Yes Artificial Joint  Yes\u003Cbr>Asthma  Yes\u003Cbr>Blood Disease  Yes\u003Cbr>Blood Transfusion  Yes\u003Cbr>Breathing Problem  Yes Bruise Easily  Yes\u003Cbr>Cancer  Yes\u003Cbr>Chemotherapy  Yes\u003Cbr>Chest Pains  Yes\u003Cbr>Cold Sores/Fever Blisters  Yes Congenital Heart Disorder  Yes Convulsions  Yes |  No\u003Cbr> No\u003Cbr> No\u003Cbr> No\u003Cbr> No\u003Cbr> No\u003Cbr> No\u003Cbr> No\u003Cbr> No\u003Cbr> No\u003Cbr> No\u003Cbr> No\u003Cbr> No\u003Cbr> No\u003Cbr> No\u003Cbr> No\u003Cbr> No\u003Cbr> No\u003Cbr> No | Cortisone Medicine Diabetes\u003Cbr>Drug Addiction Easily Winded Emphysema Epilepsy or Seizures Excessive Bleeding Excessive Thirst\u003Cbr>Fainting Spells/Dizziness Frequent Cough Frequent Diarrhea\u003Cbr>Frequent Headaches Genital Herpes Glaucoma Hay Fever\u003Cbr>Heart Attack/Failure Heart Murmur\u003Cbr>Heart Pacemaker\u003Cbr>Heart Trouble/Disease |  Yes\u003Cbr> Yes\u003Cbr> Yes\u003Cbr> Yes\u003Cbr> Yes\u003Cbr> Yes\u003Cbr> Yes\u003Cbr> Yes\u003Cbr> Yes\u003Cbr> Yes\u003Cbr> Yes\u003Cbr> Yes\u003Cbr> Yes\u003Cbr> Yes\u003Cbr> Yes\u003Cbr> Yes\u003Cbr> Yes\u003Cbr> Yes\u003Cbr> Yes |  No\u003Cbr> No\u003Cbr> No\u003Cbr> No\u003Cbr> No\u003Cbr> No\u003Cbr> No\u003Cbr> No\u003Cbr> No\u003Cbr> No\u003Cbr> No\u003Cbr> No\u003Cbr> No\u003Cbr> No\u003Cbr> No\u003Cbr> No\u003Cbr> No\u003Cbr> No\u003Cbr> No | Hemophilia\u003Cbr>Hepatitis A\u003Cbr>Hepatitis B or C Herpes\u003Cbr>High Blood Pressure High Cholesterol Hives or Rash Hypoglycemia Irregular Heartbeat Kidney Problems Leukemia\u003Cbr>Liver Disease Low Blood Pressure Lung Disease Mitral Valve Prolapse Osteoporosis\u003Cbr>Pain in Jaw Joints Parathyroid Disease Psychiatric Care\u003Cbr> Yes  No  Yes  No  Yes  No  Yes  No  Yes  No  Yes  No  Yes  No  Yes  No  Yes  No  Yes  No  Yes  No  Yes  No  Yes  No  Yes  No  Yes  No  Yes  No  Yes  No  Yes  No  Yes  No\u003Cbr>Radiation Treatments Recen","cbCaiuqL6dZSdoCS","https://ap.wps.com/l/cbCaiuqL6dZSdoCS","pdf",579893,6,"English","# Patient Information\n## Responsible Party\n## Emergency Contact\n## Pharmacy\n# Medical History\n## Questions and Condition Checklist\n# Acknowledgement and Signature\n# Authorization for Release of Identifying Health Information","[{\"question\":\"What information is required in the patient information section?\",\"answer\":\"It requests patient identification and contact details such as date of birth, first/middle/last name, preferred name, address, city/state/zip, primary and secondary phone numbers, email, and sex.\"},{\"question\":\"What topics are covered in the medical history questions?\",\"answer\":\"The form asks about physician care, past hospitalizations and major operations, serious head/neck injuries, current medications and drug history (including specific drug classes), special diet, tobacco use, controlled substances, and allergies.\"},{\"question\":\"How does the form handle responsible party details?\",\"answer\":\"If the responsible party is not the patient, it collects the responsible party’s relation to the patient, date of birth, name, address, city/state/zip, phone numbers, and identification details.\"},{\"question\":\"What does the authorization for release of identifying health information include?\",\"answer\":\"It authorizes the dental office to release health information under specified terms, including a detailed description of records to be released and the recipients who may receive the information.\"}]","Patient Registration Forms - Medical History and Authorization for Release of Health Information | PDF",1789568843]