Adult Chart - Dental Care Center

Adult Chart Form
MEDICAL HISTORY
Have you ever had a serious illness requiring hospitalization or extensive medical care?

YesNo
Are you presently under the care of a physician?

YesNo
If so explain :
Have you had a medical exam in the last year?

YesNo
Are you Pregnant or breast feeding?

YesNo
Do you use any prescription or non-prescription drugs or medications?

YesNo
Please list
Do you have any allergies?

YesNo
Please list
Do any of these allergic reactions result in headache, shortness of breath, chest constriction, or nausea?

YesNo
Specify
Have you been hospitalized in the last 2 years?

YesNo
Have you ever experienced any unusual reaction to any of the following?

local anesthesia (freezing)aspirinpenicilliniodinesulfonamides (sulfa)barbiturates (sleeping pills)
or any other medicine?

YesNo
If so Explain
Have you ever been warned against taking any drug or medication?

YesNo
Has any member of your family had diabetes?

YesNo
Do you have frequent severe headaches?

YesNo
Have you ever fainted?

YesNo
Has your Doctor or Surgeon recommended pre-medication prior to dental work?

YesNo
Have you ever experienced any unusual reaction to any of the following?

Heart Attack/Heart MurmurHepatitis A/B/CAIDSHerpesStomach/Intestinal ProblemsDrug AddictionLung DiseaseLiver DiseaseJoint Replacement/ImplantsVenereal DiseaseTuberculosisCancerMental/Nervous DisorderScarlet/Rheumatic FeverDiabetesKidney DiseaseHigh/Low Blood PressureEpilepsy/ SeizuresAnemiaSinus TroubleHyper/Hypo GlycemicArthritis/Rheumatism
Any Other Condition?
DENTAL HISTORY
When was the last time you visited a dentist?

MonthDayYear
Date
Dentist's Name
Are any of your teeth sensitive to:

ColdSweetsHeatBiting
Do your gums bleed when:

BrushingFlossingSpontaneously
How often do you brush your teeth?
How often do you floss your teeth?
Are you aware of any loose teeth?

YesNo
If so, where?
Do you clench (hold together) or grind your teeth during the day or night?

YesNo
Does your jaw crack, pop, have pain when opening and closing?

YesNo
Does food constantly get stuck between certain teeth in your mouth?

YesNo
Do you gag easily?

YesNo
Have you experienced any growth or sore spots in your mouth?

YesNo
If so, where?
Have you ever had any of the following:

Oral surgery (wisdom teeth removal)Gum SurgeryBracesTMJ treatmentSplintsOther appliance
Do you smoke?

YesNo
If so, please specify daily intake
Do you have any emotional concerns regarding your dental visit:

FearPainTimeMoneyEmbarrassmentOther
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.
PATIENT'S SIGNATURE:

Clear
FULL NAME OF PARENT/GUARDIAN
DATE

MonthDayYear
*Guardian of Child or Guardian of Adult under Guardianship
Should be Empty:

Adult Chart Form

MEDICAL HISTORY

DENTAL HISTORY