Adult Medical Dental History

Adult Medical Dental History

This form is confidential and recorded/stored securely
Patient Information
Name *

Title First Name Last Name Suffix
Preferred Name
I would like to be called
Phone Number *
Please enter a valid phone number.
Phone Carrier *
Email *
example@example.com
Please send me appointment reminders by:

Text Email
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Occupation/Employer
Date of Birth *
Gender

Female Male
How did you hear about us? *
Have any family members been treated at our office? *

Yes No
Emergency Contact
Name *

Prefix First Name Last Name Suffix
Relationship to Patient *
Phone Number *
Please enter a valid phone number.
Financial Responsibility
Who is financially responsible for your treatment? *

Self Someone Else
Guarantor Name *

First Name Last Name
Phone Number *
Please enter a valid phone number.
Email *
example@example.com
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

	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?

	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?

	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

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

Patient Information