Adult Health History
Patient Biographical Information
*First Name:
*
Middle Initial:
*Last Name:
*
Nickname:
*Marital Status:
Single
Married
*Birthdate:
*
*
Age:
*Gender:
*
Male
Female
Email:
*Address:
*
*City:
*
*State:
*
*Zip:
*
How long at this address:
Own
Rent
*Main Phone:
*
Occupation:
Employer:
Other family members seen here:
Whom may we thank for referring you?
Spouse Information
Spouse Name:
Employer:
Occupation:
Dental Insurance Information
Name of Insured:
Date of Birth:
Relationship to Patient:
Select
Self
Spouse
Other
Name of Ins. Company:
Insurance Co. Address:
Insurance Co. Phone:
Subscriber/Policy #:
Group #:
Dental History
Dentist Name:
Check-up Frequency:
Once per year
Twice per year
More than twice a year
Never
Emergencies only
Last Dental Visit:
*
Have you had an orthodontic consult or treatment?
No
Yes
If so, when?
*
By whom?
Main orthodontic concern:
Please select YES or No for the Following Questions - Do Not Leave Blank
Speech problems/therapy?
*
Yes
No
Grind or clench teeth?
*
Yes
No
Oral habits (thumb/finger sucking, lip/nail biting)?
*
Yes
No
Injury to face, jaw, teeth or mouth?
*
Yes
No
Discomfort from teeth or gums?
*
Yes
No
Pain, tenderness or noise in either jaw?
*
Yes
No
Mouth breathing?
*
Yes
No
Snores during sleep?
*
Yes
No
Any missing or extra permanent teeth?
*
Yes
No
Apprehensive about dental care?
*
Yes
No
Requires premedication?
*
Yes
No
If any of the above dental questions were answered 'Yes', please explain:
Medical History
Physician Name:
Patient Health:
Good
Excellent
Fair
Poor
List any medications you are currently taking:
Are you currently taking (or have taken in the past year) any of the following medications: Fosamax, Actonel, Boniva, Zometa, Aredia, or any other type of bisphosphonate medication to treat bone density?
*
Yes
No
List any drug allergies or sensitivities that you have:
Latex/Metal Allergy
*
Yes
No
Rheumatic Fever
*
Yes
No
Tuberculosis/Lung Disease
*
Yes
No
Pneumonia
*
Yes
No
Liver Disease
*
Yes
No
Kidney Disease
*
Yes
No
Heart Attack/Stroke
*
Yes
No
Heart Disease
*
Yes
No
Congenital Heart Defect
*
Yes
No
Heart Murmur
*
Yes
No
Hemophilia
*
Yes
No
Hypertension/High Blood Pressure
*
Yes
No
Prolonged Bleeding/Transfusion
*
Yes
No
Anemia
*
Yes
No
HIV/AIDS
*
Yes
No
Hepatitis
*
Yes
No
Cancer
*
Yes
No
Received Radiation Treatment
*
Yes
No
Growth Problems
*
Yes
No
Endocrine Problems
*
Yes
No
Hormone Therapy
*
Yes
No
Nervous Disorders
*
Yes
No
Bone Disorders/Bone Loss
*
Yes
No
Diabetes
*
Yes
No
Seizures/Epilepsy
*
Yes
No
Handicaps/Disabilities
*
Yes
No
Asthma
*
Yes
No
Arthritis
*
Yes
No
Treated for Emotional Problems
*
Yes
No
Ever Been Hospitalized
*
Yes
No
Smoke or use Tobacco
*
Yes
No
Tonsils/Adenoids Removed
*
Yes
No
Is there any other condition or problem that you think we should know about?
Do you wish to receive appointment confirmations via email?
Yes
No
Do you wish to receive text message appointment confirmations?
Yes
No