Adult Health History

Patient Health History
Patient Name: *

First Name Last Name
Birthdate: *

Month Day Year
Date
Sex: *

Male Female
Dental History
Name of Previous Dentist or Dental Clinic: *
Approximately when was your last dental cleaning? *
Approximately when were your last dental xrays taken? *
How would you describe your current dental health? *

Good Fair Poor
Are you currently experiencing any dental pain? *

Yes No
Briefly describe your pain (area, intensity, duration, etc): *
How often do you brush your teeth? *
How often do you floss? *
Do your gums bleed when you brush or floss? *

Yes, often No Sometimes
Have you ever had scaling and root planing due to periodontal disease? *

Yes No Not sure
Have you been diagnosed with gum disease (periodontal disease)? *

Yes No Not Sure
Do you have pain in your jaw joint (TMJ/TMD)? *

Yes, often No Sometimes
Do you clench or grind your teeth? *

Yes, often No Sometimes
Do you experience dry mouth? *

Yes, often No Sometimes
Do you experience headaches on a regular basis? *

Yes No
Are you happy with your smile? *

Yes No
What would you like to change? *
Are you interested in Cosmetic Dentistry? *

Yes No Maybe
Are you interested in Botox services? *

Yes No Maybe
Is there anything else you'd like Dr. Speer to know about your dental health?
Medical History
Do you have a primary physician? *

Yes No
Physician's Name: *
Physician Phone Number: *
Date of Last Visit? *

Month Day Year
Date
How would you rate your current physical health? *

Good Fair Poor
Are you currently under the care of a physician? *

Yes No
Please Explain: *
Are you taking any prescription medications? *

Yes No
Please list all prescription medications: *
Are you taking any over-the-counter medications? *

Yes No
Please list all over-the-counter medications: *
Are you taking any herbal or vitamin supplements? *

Yes No
Please list all herbal or vitamin supplements: *
Do you use any recreational drugs (legal or not)? *

Yes No
Please list all recreational drugs: *
Are you currently taking, or have you ever been prescribed osteoporosis medications, such as Fosamax? *

Yes No
Please list osteoporosis medications: *
**For Women - Please check all that apply to you:

Currently using prescription birth control Currently pregnant Currently nursing
How many weeks pregnant are you? *
Do you or have you ever used tobacco products? *

Yes No
Please elaborate (cigarettes or tobacco, how often, how long?): *
Have you ever had any of the following? *

Heart Disease Heart Attack/Stroke Angioplasty/Stents Cancer Heart Murmur Rhematic Fever HIV/AIDS Heart Surgery/Pacemaker Mitral Valve Prolapse Kidney Problems Artificial Bones/Joints Herpes/Cold Sores High Blood Pressure Low Blood Pressure Blood Transfusion Glaucoma Diabetes Type I Diabetes Type II Asthma/Emphysema/Difficulty Breathing Epilepsy/Seizures Syncope (fainting spells) Tuberculosis Drug/Alcohol Abuse Sleep Apnea Anemia Hemophillia Congenital Heart Defect Radiation Treatment Arthritis/Rheumatism Developmental Disability Hospitalization for any reason Hepatitis A Hepatitis B Hepatitis C Severe/Frequent Headaches None of the above
Do you have any allergies (medications/food/contact)? *

Yes No
Please list all known allergies: *
Is there anything else you would like Dr. Speer to know about your medical history?
By signing below, I certify that all of the information I have provided is true to the best of my knowledge. Should I have any changes to my medical or dental history, it is my responsibility to notify the providers at Oak Grove Dental Center as soon as possible.
Signature of Patient or Parent/Legal Guardian: *

Clear
Should be Empty:

Patient Health History

Dental History

Medical History