Adult Health History Form

When did you have your last medical check up?

Are you taking ANY medications
(prescription or non prescription) regularly? Please list on back of sheet if necessary

MEDICAL HISTORY

Do you consider your medical health to be good
YesNo

Do You Have Dental Insurance
YesNo

Do you have additional Dental Insurance
YesNo

Do you normally take antibiotics prior to dental treatment?
YesNo

Are you being treated by a medical doctor at this
YesNo

Have you recently gained or lost a significant amount of weight
YesNo

Have you ever had an injury to your face or Jaws?
YesNo

Do you smoke?
YesNo

Do you consume alcohol?
YesNo

HAVE YOU EVER HAD ANY OF THE FOLLOWING?

Heart Disease/Concerns
YesNo

Cancer
YesNo

Arthritis
YesNo

Radiation Treatment
YesNo

Sinus Trouble
YesNo

Diabetes
YesNo

Hay Fever/Asthma
YesNo

Lung Trouble -TB
YesNo

Psychiatric Treatment
YesNo

Rheumatic Fever
YesNo

Kidney Disease/Dialysis
YesNo

Venereal Disease
YesNo

Valve, Joint or Hip Replacement
YesNo

Liver Disease
YesNo

AIDS or HIV+(positive)
YesNo

High/Low Blood Pressure
YesNo

Epilepsy
YesNo

Herpes
YesNo

Bleeding Problems/ Blood Disease
YesNo

Ulcers
YesNo

Are you Pregnant?
YesNo

Infectious Hepatitis
YesNo

Glaucoma
YesNo

Alcohol / Drug abuse
YesNo

Organ Transplant
YesNo

Steriod use/ Therapy
YesNo

Thyroid Problems
YesNo

Stroke
YesNo

Multiple Sclerosis
YesNo

Have you ever had painful or swollen joints?
YesNo

Are you short or breath on mild exertion?
YesNo

Do you use recreational drugs (cocaine, marijuana, etc)?
YesNo

Does anyone in your family have a history of sugar diabetes?
YesNo

Have you ever been hospitalized?
YesNo

Have you had any surgeries recently?
YesNo

Are you allergic to or react to any medications or drugs (penicillin, aspirin, novacaine, etc)
YesNo

PLEASE DESCRIBE ANY other Medical Treatment, impending operations or other medical or dental information that the doctor should know about

PATIENT REGISTRATION - FOR WOMEN

Are you pregnant,or do you think you may be pregnant?
YesNo

Are you nursing?
YesNo

Are you taking oral contraceptives?
YesNo

DENTAL INFORMATION

What is the purpose of your visit today?

If this is your first visit to our office, when was your last checkup and cleaning?

Do you have any dental condition which you believe requires immediate attention today?
YesNo

Have you ever had an unusual reaction to a local anesthetic? If so, what happened and when?

Are you happy with your smile? If not, what would you like to change?

Have you ever had orthodontic treatment (braces) If so, when?

Have you ever had periodontal (gum) treatment? If so, When?

Do you wear a denture or partial?
YesNo

Upper or Lower

When was it made?

Is it comfortable?

Would it be OK with you to lose all your teeth and wear false teeth?

Have any of your teeth recently moved or separated and created spaces between them.
YesNo

Does your jaw click when you chew?
YesNo

Do you have pain in the region in front of your ears?
YesNo

Do you tend to clench or grind your teeth? If so,when (daytime/nighttime)?
YesNo

Have you ever been treated for TMJ syndrome?
YesNo

If So, When?

Do you have dark or unattractive fillings that you would like replaced?
YesNo

DO you have missing teeth you would like replaced?
YesNo

Are your gums red, swollen, receding, or do they bleed when brushing or flossing?
YesNo

Is there any other information that was not asked, which you fell may influence your dental treatment? If so, What

What is the name, address and phone number of your primary physician?

I certify that the above questions have been answered accurately.I understand that providing incorrect information can be dangerous to my health. I authorize the dentist to release any information including the diagnosis and the records of any treatment or examination rendered to me during the period of such dental care to third party payors and / health practitioners. I authorize and request my insurance company to pay
directly to the dentist insurance benefits otherwise payable to me. I understand that my dental insurance carrier may pay less than the actual dental bill for services rendered. I agree to be responsible for payment of all services rendered on my behalf or on my dependent’s behalf.

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MEDICAL HISTORY

HAVE YOU EVER HAD ANY OF THE FOLLOWING?

PATIENT REGISTRATION - FOR WOMEN

DENTAL INFORMATION