• Adult Chart Form

    Adult Chart Form

  • MEDICAL HISTORY

  • Have you ever had a serious illness requiring hospitalization or extensive medical care?
  • Are you presently under the care of a physician?
  • Have you had a medical exam in the last year?
  • Are you Pregnant or breast feeding?
  • Do you use any prescription or non-prescription drugs or medications?
  • Do you have any allergies?
  • Do any of these allergic reactions result in headache, shortness of breath, chest constriction, or nausea?
  • Have you been hospitalized in the last 2 years?
  • Have you ever experienced any unusual reaction to any of the following?
  • or any other medicine?
  • Have you ever been warned against taking any drug or medication?
  • Has any member of your family had diabetes?
  • Do you have frequent severe headaches?
  • Have you ever fainted?
  • Has your Doctor or Surgeon recommended pre-medication prior to dental work?
  • Have you ever experienced any unusual reaction to any of the following?

  • DENTAL HISTORY

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  • Are any of your teeth sensitive to:
  • Do your gums bleed when:
  • Are you aware of any loose teeth?
  • Do you clench (hold together) or grind your teeth during the day or night?
  • Does your jaw crack, pop, have pain when opening and closing?
  • Does food constantly get stuck between certain teeth in your mouth?
  • Do you gag easily?
  • Have you experienced any growth or sore spots in your mouth?
  • Have you ever had any of the following:
  • Do you smoke?
  • Do you have any emotional concerns regarding your dental visit:

  • I, the undersigned, certify that all of the medical and dental information provided is true to the best of my knowledge, and I have not knowingly omitted any information. I also consent to my physician being contacted if necessary, as this information may be required for my dental care. I also consent to the performing of dental and oral surgery procedures agreed to be necessary or advisable, including the use of local anesthetic as indicated and will assume responsibility for fees associated with these procedures.

    I consent to the collection, use, retention and disclosure of personal information as is required for my own and my dependent's dental care. 

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  • *Guardian of Child or Guardian of Adult under Guardianship

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  • Should be Empty: