Adult Health History
Language
  • English (US)
  • Español

  • Patient Health History

  • Birthdate:*
     - -
  • Sex:*

  • Dental History

  • How would you describe your current dental health?*
  • Are you currently experiencing any dental pain?*
  • Do your gums bleed when you brush or floss?*
  • Have you ever had scaling and root planing due to periodontal disease?*
  • Have you been diagnosed with gum disease (periodontal disease)?*
  • Do you have pain in your jaw joint (TMJ/TMD)?*
  • Do you clench or grind your teeth?*
  • Do you experience dry mouth?*
  • Do you experience headaches on a regular basis?*
  • Are you happy with your smile?*
  • Are you interested in Cosmetic Dentistry?*
  • Are you interested in Botox services?*

  • Medical History

  • Do you have a primary physician?*
  • Format: (000) 000-0000.
  • Date of Last Visit?*
     / /
  • How would you rate your current physical health?*
  • Are you currently under the care of a physician?*
  • Are you taking any prescription medications?*
  • Are you taking any over-the-counter medications?*
  • Are you taking any herbal or vitamin supplements?*
  • Do you use any recreational drugs (legal or not)?*
  • Are you currently taking, or have you ever been prescribed osteoporosis medications, such as Fosamax?*
  • **For Women - Please check all that apply to you:
  • Do you or have you ever used tobacco products?*
  • Have you ever had any of the following?*

  • Do you have any allergies (medications/food/contact)?*
  • Image field 47

  • 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.

  • Should be Empty: