wesmiledentistry - Medical History (Adult)

MEDICAL HISTORY (ADULT)
Patient Name *

First Name Last Name
Date *

Month Day Year
Date
Address *

Street Address

Street Address Line 2

City

Postal / Zip Code
Gender *
Birth Date *

Month Day Year
Date
Marital Status *
Home Phone Number *

Area Code Phone Number
Cell Phone Number *

Area Code Phone Number
Email Address *
example@example.com
Employer
Present Position
How Long Held
Work Phone Number

Area Code Phone Number
Do you have any insurance? *

Yes No
*

Self Other
The relationship to the patient
Name
Address

Street Address

Street Address Line 2

City

Postal / Zip Code
Date of birth

Month Day Year
Date
Insurance company name
Group/Plan Number
ID Number
Do you have secondary insurance? *

Yes No
The relationship to the patient
Name
Address

Street Address

Street Address Line 2

City

Postal / Zip Code
Date of birth

Month Day Year
Date
Insurance Company name
Group Number
Plan Number
In Case of Emergency Call
Name *

First Name Last Name
Phone Number *

Area Code Phone Number
I first learned about this dental office from *

Internet School Work
Referred By

Another Patient, Friend Another Patient, Relative Doctor/Staff Member
Name of Person Who Referred
DENTAL HISTORY
Have you been having any specific problems? *

Yes No
Describe *
Last Dental Visit?
Purpose
Last Complete Exam
Has fear of discomfort kept you from regular visits? *

Yes No
How do you describe your dental health? *

Good Fair Poor
Describe *
Do you think you have
Decay *

Yes No
Gum Disease *

Yes No
Home Care
Brush *

Yes No
Floss *

Yes No
Water Jet *

Yes No
Do your gums ever bleed? *

Yes No
How Often?
Are you troubled with bad breath? *

Yes No
How do you feel about ever losing your teeth?
Have you had any unusual effects from previous dental treatment? *

Yes No
Describe
MEDICAL HISTORY

(Confidential. Repeated every 5 year)
Date *

Month Day Year
Date
MD’s Name
Last Physical
Age
Are You Pregnant? *

Yes No
Expected Due Date

Month Day Year
Date
Are you a smoker (including Cannabis and Vaping)? *

Yes No
If yes, how long and much frequently in a day? *
Are you under a doctor’s care now? *

Yes No
If so, for what reason? *
Are you taking any medications, pills, drugs? *

Yes No
Please List
Do you have any medical conditions/concerns?

Yes No
If your answer is 'Yes', check the relevant box/es and provide details.

Heart problems Measles Diabetes Hepatitis Prosthetic Valves/Joints HIV/AIDS Mumps Arthritis Low Blood Pressure High Blood Pressure Malignancies Venereal Disease Circulatory problems Typhoid Fever Radiation treatment Herpes Excessive bleeding Nervous problems Asthma Tuberculosis Anemia Psychiatric Care Stroke Sinus problems Rheumatic fever Hospitalization Ulcer Tonsilitis Birth Control Pill or Patch Allergy to Anaesthetics Allergy to medicines/drugs Other
Provide details of Heart Problems *
Provide details of Measles *
Provide details of Diabetes *
Provide details of Hepatitis *
Provide details of Prosthetic Valves/Joints *
Provide details of HIV/AIDS *
Provide details of Mumps *
Provide details of Arthritis *
Provide details of Low Blood Pressure *
Provide details of High Blood Pressure *
Provide details of Malignancies *
Provide details of Venereal Disease *
Provide details of Circulatory problems Disease *
Provide details of Typhoid Fever *
Provide details of Radiation treatment *
Provide details of Herpes *
Provide details of Excessive bleeding *
Provide details of Nervous problems *
Provide details of Asthma *
Provide details of Tuberculosis *
Provide details of Anemia *
Provide details of Psychiatric Care *
Provide details of Stroke *
Provide details of Sinus problems *
Provide details of Rheumatic fever *
Provide details of Hospitalization *
Provide details of Ulcer *
Provide details of Tonsilitis *
Provide details of Birth Control Pill or Patch *
Provide details of Allergy to Anaesthetics *
Provide details of Allergy to medicines/drugs *
Medical Condition other than listed above:
Have you had any other serious illness? *

Yes No
Explain *
Have you been hospitalized in the last 2 years? *

Yes No
Why? *
Do you prefer Nitrous Oxide Sedation?

Yes No
Do you wish to talk to the doctor about any problem not listed? *

Yes No
Authorization: I hereby authorize the doctor and/or staff of this dental office to administer such medications and to perform such diagnostic and therapeutic procedures as may be necessary for proper dental care as agreed upon through consultation with me. The information which appears on these dental and medical histories is correct to the best of my knowledge.
Patient Signature *

Clear
Name *

First Name Last Name
Date *

Month Day Year
Date
Should be Empty:

MEDICAL HISTORY (ADULT)