Adult Health History

Adult Health/Dental History
Any information not given on this form can be collected in the office at time of visit.
Date*
Full Name*

First NameLast Name
Email Address*
Home Phone Number*

Area CodePhone Number
Work Phone Number

Area CodePhone Number
Cell Phone Number

Area CodePhone Number
Social Security Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Birth Date*

MonthDayYear
Date of Last Dental Visit

MonthDayYear
Check Appropriate Box*
Reason for this Visit*
Have you ever had any of the following*

AIDSAllergiesAnemiaArthiritisArtificial JointsAsthmaBlood DiseaseCancerDizzinessEpilepsyGlaucomaExcessive BleedingGrowthsFainting/SeizuresHay FeverHepatitisHead InjuriesHigh Blood PressureHeart DiseaseJaundiceHeart MurmorKidney DiseaseLiver DiseaseMental DisordersNervous DisordersRheumatic FeverRespiratory ProblemsRheumatismSinus ProblemsStomach ProblemsStrokeTuberculosisTumorsUlcersVenereal DiseaseRadiation TreatmentHeart AttackSwollen AnklesLow Blood PressureLeukemiaDiabetesCardiac PacemakerChest PainsFrequently TiredEmphysemaMitral Valve ProlapseArtificial Heart ValveOtherNO MEDICAL CONDITIONS
Women Only*
Have you ever had complications from dental treatment
Please list all current Medications. If no medications, enter "NONE."*
Have you been admitted to a hospital or needed emergency care in the past five years; if yes please explain
Do you have health problems that need further clarification
Name of Current Physician
Are you under the care of a physician
How did you hear about us?
Do you:*

Use tobaccoUse controlled substancesWear contact lensesHave to clear your throat oftenHave a persistent coughTake or have ever taken Fen-Phen/ReduxTake or have ever taken any bisphosphonatesNONE OF THE ABOVE
Are you allergic to any of the following?*

Local anesthetics (e.g. Novacain)Penicillin or any other antibioticsSulfa DrugsBarbituratesSedativesIodineAspirinAny metals (e.g. nickel, mercury, etc.)Latex rubberOtherNONE OF THE ABOVE
Dental History*

Do your gums bleed while brushing or flossing?Are your teeth sensitive to hot or cold liquids/food?Are your teeth sensitive to sweet or sour liquids/foods?Do you feel pain to any of your teeth?Do you have any sores or lumps in or near your mouth?Have you had any head, neck or jaw injuries?Have you ever experienced any clicking in your jaw?Have you ever experienced any pain in your jaw?Have you ever experienced any difficulty opening/closing your jaw?Have you ever experienced any difficulty chewing?Do you have frequent headaches?Do you clench or grind your teeth?Do you bite your lips or cheeks frequently?Have you ever had any prolonged bleeding after an extraction?Have you had any difficult extrations in the past?Have you had any othodontic treatment?Do you wear dentures or partials?Have you ever recieved oral hygiene instructions?Do you like your smile?NONE OF THE ABOVE
Signature
To be completed in office
Doctor's Signature
To be completed in office
Should be Empty:

Adult Health/Dental History