Adult Health History

Patient Health History
Patient Name:*

First NameLast Name
Birthdate:*

MonthDayYear
Date
Sex:*

MaleFemale
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?*

GoodFairPoor
Are you currently experiencing any dental pain?*

YesNo
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, oftenNoSometimes
Have you ever had scaling and root planing due to periodontal disease?*

YesNoNot sure
Have you been diagnosed with gum disease (periodontal disease)?*

YesNoNot Sure
Do you have pain in your jaw joint (TMJ/TMD)?*

Yes, oftenNoSometimes
Do you clench or grind your teeth?*

Yes, oftenNoSometimes
Do you experience dry mouth?*

Yes, oftenNoSometimes
Do you experience headaches on a regular basis?*

YesNo
Are you happy with your smile?*

YesNo
What would you like to change?*
Are you interested in Cosmetic Dentistry?*

YesNoMaybe
Are you interested in Botox services?*

YesNoMaybe
Is there anything else you'd like Dr. Speer to know about your dental health?
Medical History
Do you have a primary physician?*

YesNo
Physician's Name:*
Physician Phone Number:*
Date of Last Visit?*

MonthDayYear
Date
How would you rate your current physical health?*

GoodFairPoor
Are you currently under the care of a physician?*

YesNo
Please Explain:*
Are you taking any prescription medications?*

YesNo
Please list all prescription medications:*
Are you taking any over-the-counter medications?*

YesNo
Please list all over-the-counter medications:*
Are you taking any herbal or vitamin supplements?*

YesNo
Please list all herbal or vitamin supplements:*
Do you use any recreational drugs (legal or not)?*

YesNo
Please list all recreational drugs:*
Are you currently taking, or have you ever been prescribed osteoporosis medications, such as Fosamax?*

YesNo
Please list osteoporosis medications:*
**For Women - Please check all that apply to you:

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

YesNo
Please elaborate (cigarettes or tobacco, how often, how long?):*
Have you ever had any of the following?*

Heart DiseaseHeart Attack/StrokeAngioplasty/StentsCancerHeart MurmurRhematic FeverHIV/AIDSHeart Surgery/PacemakerMitral Valve ProlapseKidney ProblemsArtificial Bones/JointsHerpes/Cold SoresHigh Blood PressureLow Blood PressureBlood TransfusionGlaucomaDiabetes Type IDiabetes Type IIAsthma/Emphysema/Difficulty BreathingEpilepsy/SeizuresSyncope (fainting spells)TuberculosisDrug/Alcohol AbuseSleep ApneaAnemiaHemophilliaCongenital Heart DefectRadiation TreatmentArthritis/RheumatismDevelopmental DisabilityHospitalization for any reasonHepatitis AHepatitis BHepatitis CSevere/Frequent HeadachesNone of the aboveOther
Do you have any allergies (medications/food/contact)?*

YesNo
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