Patient Medical History (Adult) Form
Today's Date
-
Month
-
Day
Year
Date
Patient's Name
First Name
Last Name
Nickname
D.O.B.
-
Month
-
Day
Year
Date
Age
Gender
Please Select
Male
Female
Name of Your Physician
Office Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Physician's Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Last Exam
-
Month
-
Day
Year
Date
Are you in good health?
Yes
No
Do you have a health problem?
Yes
No
If yes, please explain:
Have you ever been hospitalized, had general anesthesia, or emergency room visit?
Yes
No
Are your immunizations up to date?
Yes
No
Do you have allergies to medications (drugs), medical products (latex) or the environment (dust, mites, pollen, mold)?
Yes
No
List past medications taken:
List daily medications you are now taking:
Have you ever had or been treated by a physician for:
Rows
Yes
No
Birth Problems
Heart Murmur
Heart Disease
Rheumatic Fever
Anemia
Sickle Cell Anemia
Bleeding/Hemophilia
Blood Transfusion
Hepatitis
AIDS or HIV+
Tuberculosis
Liver Disease
Kidney Disease
Diabetes
Arthritis
Cancer
Cerebral Palsy
Seizures
Asthma
Cleft Lip/Palate
Speech or Hearing Problems
Eye Problems/Contact Lenses
Skin Problems
Tonsil/Adenoid/Sinus Problems
Sleep Problems
Emotional/Behavioral Problems
Radiation Therapy
Growth Problems
Attention Deficit Disorder
What is your main concern about your dental condition?
Have you been to the dentist before?
Yes
No
If yes, date of last visit:
-
Month
-
Day
Year
Date
Regular Dentist's Name
Please answer each of the following questions.
Rows
Yes
No
Have you had cavities and/or toothaches?
Are your teeth sensitive to temperature or food?
Did you ever get instructions on how to brush their teeth?
Do your gums bleed when brushed?
Do you use fluoride products: rinses, drops, tabs?
Do you experience any clicking or pain in the jaw joint?
Do you have any problems opening or closing their mouth?
Have you ever injured your teeth?
Have you ever injured your jaw or face?
Did you ever use a pacifier?
Did/do you suck their fingers or thumbs?
Have you ever had dental X-rays before?
Yes
No
Date of last dental X-rays?
-
Month
-
Day
Year
Date
Will you be uncooperative?
Yes
No
If yes, please explain:
Have experienced any complications following dental treatment?
Yes
No
If yes, please explain:
Have you inherited any family facial or dental characteristics?
Yes
No
If yes, please explain:
Demographic Information
Residential Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mailing Address (if different)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Cell Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Work Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Employer
Occupation
No. of Years Employed
Spouse's Name
First Name
Last Name
Spouse's D.O.B.
-
Month
-
Day
Year
Date
Gender
Please Select
Male
Female
Home Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Cell Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Work Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Employer
Occupation
No. of Years Employed
Insurance Information
Insured's Name
First Name
Last Name
Insured's Birthdate
-
Month
-
Day
Year
Date
Insured's ID #
*
If this does not apply to you, type "N/A"
Insured's Group #
Insurance Company
Insured's Employer
Insurance Company Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Insurance Company Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Do you have Dual Coverage?
Yes
No
Insured's Name
First Name
Last Name
Insured's Birthdate
-
Month
-
Day
Year
Date
Insured's ID #
Insured's Group #
Insurance Company
Insured's Employer
Insurance Company Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Insurance Company Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Do you have any other dental problems we should know about?
Whom may we thank for referring you to our office?
Signature of Person Completing this Form
Relationship to Patient
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