Adult Patient Information/Medical History

Today's Date

Personal Info

Last Name

First Name

Middle Initial

Preference

Home Address

City

State

Zip

Home Phone #

Cell Phone #

Work #

Message #

Date of Birth

Age

Sex

Marital Status

Social Security #

Drivers License #

Email Address

Employment Info

Employer

Employer's Address

Occupation

Length of Employment

Email Address

Spouse/Parent Info

Spouse or Parent Name

Home Address

Home Phone #

Cell Phone #

Social Security #

Date of Birth

Employer

Work Phone #

Emergency Contact Info

Name & Relation

Home Phone #

Work Phone #

Cell Phone #

Dental History

What is your goal for your dental care at our office?

How did you hear of our office?

Previous/Present Dentist

Last Dental Visit

What work was done?

Health

Physician Name

Phone #

How would you view your current physical health?

Good

Fair

Poor

Do you have or had any of the following:

Artificial Bones/Joint/Valves

Yes

HIV/AIDS

Yes

Diabetes

Yes

Blood Transfusion

Yes

If yes, specify year

Congenital Heart Defect

Yes

Heart Attack/Stroke

Yes

If yes, specify date

Heart Murmur

Yes

Heart Surgery/Pacemaker

Yes

If yes, specify date

High/Low Blood Pressure

Yes

Mitral Valve Prolapse

Yes

Hepatitis

Yes

If yes, specify type

Liver Disease/Jaundice

Yes

Rheumatic/Scarlet Fever

Yes

If yes, specify date

Abnormal Bleeding/Aspirin Use

Yes

Alcohol/Drug Abuse

Yes

Arthritis

Yes

Cancer/Chemotherapy

Yes

Colitis/Ulcer

Yes

Difficulty Breathing/Persistent Cough

Yes

Emphysema/Tuberculosis

Yes

Asthma

Yes

Epilepsy/Seizures/Fainting Spells

Yes

Fever Blisters/Herpes/Cold Sores

Yes

Tonsillitis

Yes

Headache Severe/Frequent

Yes

Kidney Problems

Yes

Psychiatric Problems

Yes

Sickle Cell Disease

Yes

Steroid Therapy

Yes

Osteoporosis

Yes

Thyroid Problems

Yes

Have you ever been hospitalized for any reason?

Allergies

Motrin (Ibuprofen)

Yes

Dental Anesthetics

Yes

Codeine

Yes

Clindamycin

Yes

Latex

Yes

Penicillin

Yes

Additional Allergies

Please list any prescription or over the counter medication you are taking (if you have a list we can photocopy it)

Have you ever taken Bisphosphonate drugs? (drugs for Osteoporosis)

Yes

Do you use tobacco in any form?

Yes

If yes, please specify type

If yes, how much

For Women

Are you taking birth control medication?

Yes

Are you pregnant?

Yes

If yes, how many months?

Are you nursing?

Yes

How would you view your current dental health?

Good

Fair

Poor

Do you like your smile?

Yes

Have you ever had a serious/difficult problem with any previous dental work?

Yes

Do you now or have yo ever experienced pain/discomfort in your jaw joint?

Yes

Have you ever had gum treatment?

Yes

Do your gums ever bleed?

Yes

If yes, when?

How many times per week do you floss?

How many times per day do you floss?

How many times a day do you brush?

How long do you use a toothbrush before replacing it?

Type of bristles?

Are your teeth sensitive to heat, cold, or anything else?

Have you lost any teeth?

Yes

If yes, why?

I UNDERSTAND THAT THE ABOVE INFORMATION IS CORRECT TO THE BEST OF MY KNOWLEDGE. I UNDERSTAND THAT IT IS MY RESPONSIBILITY TO INFORM THIS OFFICE OF ANY CHANGE IN MY MEDICAL STATUS. I UNDERSTAND THAT, ON THE DATE OF SERVICE, I AM RESPONSIBLE FOR PAYMENT OF SERVICES RENDERED AS WELL AS PAYING ANY CO-PAY AND DEDUCTIBLE THAT MY DENTAL BENEFITS DOES NOT COVER. DUE TO THE INCREASED NUMBER OF BROKEN APPOINTMENTS THERE WILL BE A CHARGE OF $55.00 PER ½ HOUR OF APPOINTMENT TIME BILLED TO YOUR ACCOUNT FOR MISSED APPOINTMENTS WITHOUT 48 HOURS NOTICE. WHEN YOU MAKE AN APPOINTMENT WE CONSIDER THAT AS YOUR CONFIRMATION. WE WILL ATTEMPT A COURTESY CALL 1-2 DAYS PRIOR TO YOUR SCHEDULED TIME. HOWEVER, IF WE CANNOT REACH YOU OR YOU DO NOT GET THE MESSAGE, THE APPOINTMENT IS STILL YOUR RESPONSIBILITY.

Signature

Date

Relationship

Submit

Thank You!

We appreciate you taking the time to complete this form. We'll review the information submitted and be in touch with you if anything additional is required.

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