Adult Welcome & Medical History Form

Medical History Form

Patient Name*

Date*

Conditions:

Acid Reflux/GERD*

Yes
No

ADD/ADHD*

Yes
No

AIDS/HIV*

Yes
No

Alzheimers/Dementia*

Yes
No

Anemia/Iron Deficiency*

Yes
No

Arthritis*

Yes
No

Artificial Joints*

Yes
No

Asthma*

Yes
No

Autism*

Yes
No

Back Problems*

Yes
No

Cancer*

Yes
No

Cerebral Palsy*

Yes
No

Chemotherapy/Radiation*

Yes
No

Congenital Birth Defects*

Yes
No

COPD/Respiratory*

Yes
No

Depression/Anxiety*

Yes
No

Developmental Delay*

Yes
No

Diabetes*

Yes
No

Down Syndrome*

Yes
No

Eating Disorder*

Yes
No

Emotional/Mental Disabilities*

Yes
No

Epilepsy/Seizures or Fainting*

Yes
No

Eyesight Problems*

Yes
No

G-Tube*

Yes
No

Hearing Loss*

Yes
No

Heart Conditions/Disorders*

Yes
No

Hepatitis A, B, C*

Yes
No

High Blood Pressure*

Yes
No

High Cholesterol*

Yes
No

Infections*

Yes
No

Kidney Problems*

Yes
No

Low Blood Pressure*

Yes
No

Lupus*

Yes
No

Osteoporosis*

Yes
No

Rapid Weight Loss/Gain*

Yes
No

Rheumatic Fever*

Yes
No

Second Hand Smoke*

Yes
No

Sexually Transmitted Infection*

Yes
No

Stomach Problems/Ulcers*

Yes
No

Stroke*

Yes
No

Substance Abuse*

Yes
No

Thyroid Issues*

Yes
No

Tuberculosis*

Yes
No

Other Conditions:

Allergies:

Amoxicillin*

Yes
No

Aspirin*

Yes
No

Codeine*

Yes
No

Dental Anesthetics*

Yes
No

Erythromycin*

Yes
No

Latex*

Yes
No

Metals*

Yes
No

Penicillin*

Yes
No

Red Dye*

Yes
No

Seasonal/Environmental*

Yes
No

Sulfa*

Yes
No

Tetracycline*

Yes
No

Other Allergies:

Dental Questionnaire:

1. Do your gums bleed while brushing or flossing*

Yes
No

2. Are your teeth sensitive to hot, cold, or sweet liquids or foods?*

Yes
No

3. Are any of your teeth painful?*

Yes
No

4. Do you have any sores/lumps in or near your mouth?*

Yes
No

5. Have you had any head, neck or jaw injuries?*

Yes
No

6. Have you experienced any of the following:

a. Clicking*

Yes
No

b. Pain (joint, ear, side or face)*

Yes
No

c. Difficulty in opening or closing*

Yes
No

d. Difficulty chewing*

Yes
No

7. Do you have frequent headaches?*

Yes
No

8. Do you clench or grind your teeth?*

Yes
No

If yes, do you wear a bite splint?

9. Do you bite your lips or cheeks?*

Yes
No

10. Have you had braces or Invisalign?*

Yes
No

If yes, do you wear retainers?

11. Do you wear dentures or partials?*

Yes
No

12. If you could change anything about your smile...?:

a. Whiter?*

Yes
No

b. Shape and/or spaces?*

Yes
No

c. Straighter?*

Yes
No

d. Bad Breath?*

Yes
No

e. Missing Teeth?*

Yes
No

Medical Questionnaire:

1. Are you under medical treatment now?*

Yes
No

2. Have you been hospitalized for any surgical operations or serious illness within the last 5 years?*

Yes
No

If yes, for what?

3. Has you been out of the country in the last 3 weeks?*

Yes
No

a. If yes, have you been sick or felt under the weather?

Yes
No

4. Are you taking any medication(s) including non-prescription, supplements, and vitamins?*

Yes
No

Please List:

5. Do you have sleep apnea?*

Yes
No

6. Chew/smoke tobacco, marijuana, or vape?*

Yes
No

7. Do you use controlled substances?*

Yes
No

8. Other Comments:

9. Women Only:

a. Are you pregnant or think you may be pregnant?

Yes
No

b. If yes, how many weeks?

c. Are you nursing?

Yes
No

d. Are you taking oral contraceptives?

Yes
No

10. Physician's Name*

a. Physician's Phone #*

b. Preferred Pharmacy

Authorization and Release

I certify that I have read and understand the above information to the best of my knowledge. The above questions have been accurately answered. I understand that providing incorrect information can be dangerous to my health. If a medical emergency arises in office, a complete medical history is needed to provide you with the best care and efficiency. I authorize the dentist to release any information including the diagnosis and the records of any treatment or examination rendered to me or my child during the period of such dental care to third party payors and/or health practitioners. I authorize and request my insurance company to pay directly to the dentist or dental group insurance benefits otherwise payable to me. I understand that my dental insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf or my dependents.

Signature of Patient (Parent/Legal Guardian)*

Printed Name*

Date*

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Adult Welcome & Medical History Form