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Adult Health Form
Adult Health Form
Adult Health Form
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Patient Information
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*
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Zip Code
*
Birthdate
*
Social Security Number
*
Spouse's Name
Spouse's Employer
Previous Dentist
*
Primary Physician
*
Physician's Phone Number
*
How did you hear about us?
*
When was your last dental visit?
Please list any medications you are taking:
Should it be necessary for us to prescribe medication, what pharmacy do you use?
*
Emergency Contact Name
Emergency Contact Relationship
*
Emergency Contact Phone Number
*
Health Information
Please select Yes or No to the following:
Heart Problems
*
Yes
No
Blood Disorder
*
Yes
No
Heart Attack
*
Yes
No
Pacemaker
*
Yes
No
Respiratory Problems
*
Yes
No
Herpes
*
Yes
No
Thyroid Problems
*
Yes
No
Epilepsy
*
Yes
No
Do you smoke?
*
Yes
No
Joint Replacement
*
Yes
No
Kidney Problems
*
Yes
No
Dialysis
*
Yes
No
Tuberculosis
*
Yes
No
HIV Positive
*
Yes
No
Cancer/chemotherapy
*
Yes
No
Do you sleep walk?
*
Yes
No
Hepatitis
*
Yes
No
Tonsil/adenoidectomy
*
Yes
No
Asthma
*
Yes
No
Diabetes
*
Yes
No
High/ Low Blood Pressure
*
Yes
No
Sinus Trouble
*
Yes
No
Acid Reflux
*
Yes
No
Bleeding Problems
*
Yes
No
Frequent Headaches
*
Yes
No
Are you pregnant?
*
Yes
No
Lyme Disease
*
Yes
No
Are you allergic to any of the following?
Penicillin
Local Anesthetic
Codeine
Latex
Other
Other
Are your teeth sensitive to any of the following?
Hot
Cold
Sweets
Biting Pressure
Does food catch between your teeth?
*
Yes
No
Do your gums bleed when brushing?
*
Yes
No
Are you dissatisfied with the appearance of your teeth?
*
Yes
No
What are you unhappy with?
Do you wish your teeth were whiter?
*
Yes
No
Do you have any loose teeth?
*
Yes
No
Have you had any teeth removed?
*
Yes
No
When?
Are you dissatisfied with how your teeth function when eating?
*
Yes
No
Do you brush your teeth less than twice a day?
*
Yes
No
Do you notice an unpleasant taste or odor in your mouth?
*
Yes
No
Do you feel you will eventually wear dentures?
*
Yes
No
Why?
Do you clench your teeth?
*
Yes
No
Do you grind your teeth during the day or night?
*
Yes
No
Do you have discomfort anywhere in your mouth or jaw?
*
Yes
No
Does your jaw pop or click?
*
Yes
No
Do you get frequent headaches?
*
Yes
No
Location?
Do you have limited mouth opening?
*
Yes
No
Do you have tingling in your fingers?
*
Yes
No
Do you have ear congestion?
*
Yes
No
Do you notice ringing in your ears?
*
Yes
No
Do you receive Botox injections?
*
Yes
No
Do you snore?
*
Yes
No
Does your snoring disturb people?
*
Yes
No
Can you breathe through your nose?
*
Yes
No
Do you have trouble getting to sleep and/or staying asleep?
*
Yes
No
Have you ever been told that you stop breathing, or gasp for air when you sleep?
*
Yes
No
Have you ever been diagnosed with sleep apnea?
*
Yes
No
Do you use a CPAP machine?
*
Yes
No
Is there anything else you think we should know?
*
Yes
No
Please explain:
*
I certify that the information above is correct*
Primary Dental Insurance
Insurance Carrier
*
Address
*
Subscriber (Employee)
*
Employee Social Security Number
*
Employee Date of Birth
*
Employer
*
Group Number
*
Secondary Insurance?
Yes
No
Secondary Dental Insurance
Insurance Carrier
Address
Subscriber (Employee)
Employee Social Security Number
Employee Date of Birth
Employer
Group Number
Name
This field is for validation purposes and should be left unchanged.
