New Adult Health History

Confidential Health Questionnaire

Patient's Name

Date

Age

Social Security Number

Patient's Home Address

City

State

Zip Code

Home Telephone Number

Cell Phone Number

Email address

Employer's Name

Work Telephone Number

Employer's Address

City

State

Zip Code

Spouse's Name

Spouse's Birthdate

Spouse's Social Security Number

Spouse's Cell Phone Number

Spouse's Email Address

Spouse's Employer's Name

Spouse's Work Telephone Number

Spouse's Employer's Address

City

State

Zip Code

Dental Insurance

Carrier of Plan - Subscriber

SS# of Subscriber

Group Number or Plan ID Number

Effective Date

Secondary Dental Insurance

Carrier of Plan - Subscriber

SS# of Subscriber

Group Number or Plan ID Number

Effective Date

Physician's Name

Phone Number

City

State

Referred to our office by:

Medical History

Are you being treated for any condition by a physician now?

Yes No

If yes, what is the condition?

When was your last physical examination?

Has there been any change in your health in the last year?

Yes No

Add additional medication

Have you ever experienced a bad reaction with dental anesthetic?

Yes No

Have you ever had surgery or x-ray treatment for a tumor, growth, or other condition in your mouth or your lips?

Yes No

Add additional hospitalization

Add additional operation

Have you ever taken any diet or weight control medications?

Yes No

If yes, what?

If you have any disease, condition, or problem not listed above that you think I should know about, please explain:

Have you ever experienced a bad reaction to any of the following drugs?

Aspirin

Penicillin

Iodine

Sulfonamides, Sulfa

Barbiturates, Sleeping Pills

Codeine

Tetracycline

Clindamycin

Add another reaction

Add another herbal supplement

Do you have any chest pain on exertion?

Yes No

Is there a history of Diabetes in your family?

Yes No

With whom?

Do you have a tendency to faint?

Yes No

Are you pregnant?

Yes No

Are you nursing?

Yes No

Are you taking birth control pills?

Yes No

Dental History

Are you dissatisfied with the appearance of your teeth?

Yes No

Are you worried about receiving dental treatment?

Yes No

Do you have difficulty chewing your food?

Yes No

Are your teeth sensitive to cold, heat, or sweets?

Yes No

Have you had a toothache recently?

Yes No

Do you have bleeding gums?

Yes No

When and where?

Do you have frequent canker sores or cold sores?

Yes No

Have you noticed any bad odors or tastes from your mouth?

Yes No

Have you ever had Vincent's infection or trench mouth?

Yes No

Is it difficult for you to open your mouth as wide as you would like?

Yes No

Does your jaw click when you chew?

Yes No

Do you ever have pain in the region in front of your ears?

Yes No

Have you ever worn a bite splint or guard?

Yes No

Do you clench or grind your teeth?

Yes No

Do you have any habits such as biting your nails, chewing on a pen or pencil, etc.?

Yes No

If yes, please explain.

Have you been under more than average stress or tension?

Yes No

When did you last have your teeth cleaned?

How frequently have you had your teeth cleaned in the last 10 years?

Have you ever had orthodontic treatment?

Yes No

Have you ever had periodontal, gum, treatment?

Yes No

Approximate date of last tooth extraction, and reason:

Have you ever had endodontic, root canal, treatment?

Yes No

Have any of your teeth recently separated creating space between them?

Yes No

Does food wedge between any of your teeth?

Yes No

Do you wear a removal bridge and/or denture?

Yes No

How many years?

Is it worn at night?

Is it comfortable?

Have you noticed any loose teeth?

Yes No

Where?

How many times per day do you brush your teeth? When?

Do you use dental floss, rubber tips, or stimudents daily?

Yes No

Which?

Do you smoke?

Yes No

What and how much?

Would you be greatly disturbed if you had to lose all your natural teeth and wear false teeth?

Yes No

To your knowledge, is there any history of periodontal (gum) disease in your family?

Yes No

Please add any information you feel is important.

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