Adult Medical Dental History

Does you have a primary care physician?*

YesNo

Primary Physician Name

City, State

Last seen month/year?

Reason?

Next appointment month/year?

Last physical exam month/year?

Does you see other physicians?

YesNo

Please list any other physicians you see

Physician Name 1 City, State 1 Reason 1
Physician Name 2 City, State 2 Reason 2

Have you been hospitalized in the past 5 years?

YesNo

Please explain

Now or in the past, have you had?*

	Yes	No	Don't Know/Understand
Have you ever taken IV medication for bone disorders?
Have you ever taken oral medication for bone disorders?
Birth defects or hereditary problems?
Bone fractures or major injuries?
Any injuries to face, head, neck?
Endocrine or thyroid problems?
Diabetes or low blood sugar?
Kidney problems?
Cancer, tumor, radiation treatment, or chemotherapy?
Stomach ulcer, hyperacidity, acid reflux?
Immune system problems?
History of osteoporosis?
Gonorrhea, syphilis, herpes, sexually transmitted infections?
AIDS or HIV positive?
Hepatitis, jaundice, or other liver problem?
Polio, mononucleosis, tuberculosis, or pneumonia?
Seizures, fainting spells, or neurologic problems?
Mental health disturbance or depression?
Vision, hearing, or speech problems?
History of eating disorder (anorexia, bulimia)?
High or low blood pressure?
Excessive bleeding or bruising, anemia?
Chest pain, shortness of breath, tire easily, swollen ankles?
Heart defects, heart murmur, rheumatic heart disease?
Angina, arteriosclerosis, stroke, or heart attack?
Skin disorder (other than common acne)?
Do you eat a well balance diet?
Frequent headaches or migraines?
Frequent ear infections, colds, throat infections?
Asthma, sinus problems, hayfever?
Tonsil or adenoid condition?
Do you frequently breathe through your mouth?

Have you had allergies or reactions to the following?*

	Yes	No	Don't Know/Understand
Latex (gloves, balloons)
Metals (jewelry, clothing snaps)
Acrylics
Local anesthetics (Benzocaine, Lidocaine)
Aspirin
Ibuprofen (Motrin, Advil)
Penicillin
Other antibiotics
Plant pollens
Animals
Foods

For women:*

	Yes	No	Don't Know/Understand
Are you pregnant?
Are you trying to become pregnant?

Please list any other medical conditions or allergies that you may have:

Have your parents or siblings ever had bleeding disorders, diabetes, arthritis, severe allergies, or other genetic medical conditions?*

YesNo

Please explain

Do you take any medications, nutritional supplements, herbal medications or non-prescription medicines, including fluoride supplements?*

YesNo

Please list any medication, nutritional supplement, herbal medication or non-prescription medicines you take.

Medication 1 taken for Reason 1
taken for
taken for
taken for
Medication 5 taken forReason 5
Medication 6 taken forReason 6
Medication 7 taken forReason 7
Medication 8 taken forReason 8

Do you chew/smoke tobacco or vape?*

YesNo

Do you currently have (or have you ever had) a substance abuse problem?*

YesNo

	Yes	No	Don't Know/Understand
Extractions of permanent or extra teeth?
Extra or missing teeth?
Chipped or injured primary or permanent teeth?
Any sensitive or sore teeth?
Bleeding gums, bad taste or mouth odor?
Jaw fractures, cysts, infections?
Any teeth treated with root canals or pulpotomies?
History of cold or canker sores?
History of speech issues or therapy?
Difficulty breathing through nose?
Food gets stuck between teeth?
Mouth breathing habit or snoring at night?
Oral habits (finger sucking, nail biting, pen chewing)
Abnormal swallowing (tongue thrust)
Tooth grinding or clenching?
Clicking, locking in jaw joints?
Soreness in jaw or facial muscles?
Ringing in ears, difficulty in chewing or opening jaw?
Previous treatment for "TMJ" or "TMD" problems?
Any broken or missing fillings?
Any trouble associated with previous dental treatment?
History of gum disease or periodontitis?
Frequent dry mouth?

Adult Medical Dental History

Patient Information

Emergency Contact

Financial Responsibility

Dental Information

Dental Insurance

Dental History

Orthodontic History

Medical Information

Medical History

Medication

Releases and Waivers