Adult Patient Information/Medical History

Personal Info

Name

Date of Birth

Home Address

City

State

Zip

Home Phone #

Cell Phone #

Email Address

EMERGENCY CONTACT INFO

Name & Relation

Home/Cell #

HEALTH

Physician Name

Phone #

How would you view your current physical health?

Good

Fair

Poor

Have you had/experienced 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

Emphysema/ Tuberculosis/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?

Yes

If hospitalized, why?

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

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

Yes

Do your gums ever bleed?

Yes

If yes, when?

How many times a day do you brush?

How often do you floss?

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

For Women

Are you taking birth control medication?

Yes

Are you pregnant?

Yes

If yes, how many months?

Are you nursing?

Yes

I understand that the information that I have given today is correct to the best of my knowledge. I understand that it is my responsibility to inform this office of any change in my child's medical status. I understand that I am responsible for payment of services rendered and also for paying any co-pay and deductible that my Dental Benefit does not cover on the date of service. We schedule your time for your child and for your child only. Because of this, 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. We will try to confirm appointments 1-2 days prior to your scheduled time. However, if we can not reach you or you do not get the message, the appointment is still your responsibility.

Signature

Date

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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