Dr. Cruz Adult Health History Form

Adult Health History Form
About you
Today's Date

MonthDay Year
Date
Email Address :*
example@example.com
Patient Name :*

First Name Middle Name Last Name
I prefer to be called :
Gender :

MaleFemale
Birthday :*

MonthDay Year
Date
Age:
Social Security #:
Marital Status :*

SingleMarriedPartneredDivorced/SeparatedWidowed
Home Address:*

Street Address

Street Address Line 2

City State

Zip Code
Cell #:
Home Phone #:
Work Phone #:
Where & when are best times to reach you? *
Whom may we Thank for referring you?
Other family members seen by us :
Employment
Employer:
How long there?
Occupation
Employer's address:

Street Address

Street Address Line 2

City State

Zip Code
Neighbor or Relative not living with you
His/Her Name
Relation
Address:

Street Address

Street Address Line 2

City State

Zip Code
Home phone #:
Work phone #:
Person Responsible for Account if other then yourself
His/Her Name
Relation
Social Security #:
Employer:
Contact #:
Driving License
Billing address:

Street Address

Street Address Line 2

City State

Zip Code
Spouse Information
His/Her Name
Birthdday

MonthDay Year
Date
Social Security #:
Employer:
Contact #:
Driving License
Address:

Street Address

Street Address Line 2

City State

Zip Code
Insurance information
Primary insurance
Dental Coverage?

YesNo
Medical Coverage?

YesNo
Orthodontic Coverage

YesNo
Insurance Co. name:
Insurance Co. Address :

Street Address

Street Address Line 2

City State

Zip Code
Phone:
Group# (Plan, Local or Policy#):
Insured’s Name :
Insured’s Social Security # :
Insured’s Birthday :

MonthDay Year
Date
Relation:
Insured’s Employer :
Employer's Address :

Street Address

Street Address Line 2

City State

Zip Code
Secondary insurance
Dental Coverage?

YesNo
Medical Coverage?

YesNo
Orthodontic Coverage

YesNo
Insurance Co. name:
Insurance Co. Address :

Street Address

Street Address Line 2

City State

Zip Code
Phone:
Group# (Plan, Local or Policy#):
Insured’s Name :
Insured’s Social Security # :
Insured’s Birthday :

MonthDay Year
Date
Relation:
Insured’s Employer :
Employer's Address :

Street Address

Street Address Line 2

City State

Zip Code
Dental History
Why have you come to the dentist today?
Are you currently in pain

YesNo
Do you require antibiotics before dental treatment?

YesNo
Have you experienced problems associated with any previous dental work?

YesNo
Do you now or have you ever experienced pain or discomfort in you jaw joint (TMD/TMJ)?

YesNo
Your current dental health is:

GoodFairPoor
Do you floss daily?

YesNo
Brush daily?

YesNo
Type of bristles on your toothbrush

HardMediumSoft
How long do you use a toothbrush before replacing it
"Do you use anything in addition to your brush or floss"

YesNo
If Yes, what?
Would you like fresher breath?

YesNo
Whiter teeth?

YesNo
Do your gums ever bleed?

YesNo
Ever itch?

YesNo
Have you ever had Periodontal disease?

YesNo
Do you have mobility in your teeth?

YesNo
Are your teeth sensitive to heat, cold or anything else?
Do you still have wisdom teeth

YesNo
If Yes, why?
Previous/Present Dentist
Date of last visit:

MonthDay Year
Date
Reason for leaving your last dentist?
Are you happy with the way your teeth look and feel?

YesNo
If not, what would you change?
Medical History
Do you have a personal physician?

YesNo
Physician’s Name :
Phone #:
Date of last visit :

MonthDay Year
Date
Physician’s Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Your current physical health is :

GoodFairPoor
Are you currently under the care of a physician?

GoodFairPoor
Please explain :
Have you ever taken Fosamax, or any other bisphosphonate?

YesNo
Have you ever been told that you snore or hold your breath while sleeping or wake up gasping for breath?

YesNo
Do you smoke or use tobacco in any other form?

YesNo
For Women
Are you taking birth control pills?

YesNo
Are you pregnant ?

UnsureYesNo
Week # :
Are you nursing ?

YesNo
Are you allergic to any of the following?

AspirinBarbituratesCodeineDental AnestheticsErythromycinJewelry MetalsLatexPenicillinSedativesSulfa DrugsTetracycline
Are you taking any of the following?

AcetaminophenAntibioticsAntihistaminesAspirinBlood Pressure MedicationBlood ThinnersCold RemediesDigitalis/Heart MedicationInsulin/Diabetes DrugsNitroglycerineRecreational DrugsSteroids/CortisoneThyroid MedicineTranquilizers
Have you ever taken Phen-Fen along known as Redux or Pondimin?

YesNo
Are you taking any prescription/over-the-counter drugs not listed above?

YesNo
If Yes, please list each one
Have you experienced the following?

Abnormal BleedingAlcohol AbuseAnemiaArthritisArtificial Heart ValvesArtificial JointsAsthmaBlood TransfusionCancerChemotherapyChicken PoxColitisCongenital Heart DefectsDiabetesDifficulty BreathingDrug abuseEmphysemaEpilepsyFainting SpellsFever BlistersGlaucomaHay FeverHeadachesHeart AttackHeart MurmurHeart SurgeryHemophiliaHepatitisHerpesHigh Blood PressureHIV+ /AIDSHospitalizationsKidney ProblemsLiver DiseaseLow Blood PressureLupusMitral Valve ProlapsePacemakerPersistent CoughPsychiatric ProblemsRadiation TreatmentRheumatic FeverScarlet FeverSeizuresShinglesSickle Cell DiseaseSinus ProblemsStrokeThyroid ProblemsTonsillitisTuberculosisUlcersVenereal Disease
Please list any other serious medical condition(s) that you have ever had :
I affirm that the information I have given is correct to the best of my knowledge. It will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my medical status. I authorize the dental staff to perform the necessary dental services I may need.
I understand that I am responsible for the payment of all services rendered.
Patient Signature*

Clear
Date :

MonthDay Year
Date
Should be Empty:

Adult Health History Form

About you

Employment

Neighbor or Relative not living with you

Person Responsible for Account if other then yourself

Spouse Information

Insurance information

Primary insurance

Secondary insurance

Dental History

Medical History