Adult Health/Dental History FormEmail Today's Date As required by law, our office adheres to written policies and procedures to protect the privacy of information about you that we create, receive or maintain. Your answers are for our records only and will be kept confidential subject to applicable laws. Please note that you will be asked some questions about your responses to this questionnaire and there may be additional questions concerning your health. This information is vital to allow us to provide appropriate care for you. This office does not use this information to discriminate.Name* Last First Middle Home Phone: Include area codeBusiness/Cell Phone: Include area codeAddress Mailing Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Zip Code OccupationHeightWeightDate of Birth Sex* M F SS# or Patient IDEmergency ContactRelationshipHome PhoneCell PhoneIf you are completing this form for another person, what is your relationship to that person? Your Name Relationship Do you have any of the following diseases or problems: (Check DK if you Don't Know the answer to the question)Active Tuberculosis Yes No DK Persistent cough greater than a 3 week duration Yes No DK Cough that produces blood Yes No DK Been exposed to anyone with tuberculosis Yes No DK If you answer yes to any of the 4 items above, please stop and return this form to the receptionist.Dental InformationDo your gums bleed when you brush or floss? Yes No DK Do you have earaches or neck pains? Yes No DK Are your teeth sensitive to cold, hot, sweets or pressure? Yes No DK Do you have any clicking, popping or discomfort in the jaw? Yes No DK Does food or floss catch between your teeth? Yes No DK Do you brux or grind your teeth? Yes No DK Is your mouth dry? Yes No DK Do you have sores or ulcers in your mouth? Yes No DK Have you had any periodontal (gum) treatments? Yes No DK Do you wear dentures or partials? Yes No DK Have you ever had orthodontic (braces) treatment? Yes No DK Do you participate in active recreational activities? Yes No DK Have you had any problems associated with previous dental treatment? Yes No DK Have you ever had a serious injury to your head or mouth? Yes No DK Is your home water supply fluoridated? Yes No DK Do you drink bottled or filtered water? Yes No DK If yes, how often? Daily Weekly Occasionally Are you currently experiencing dental pain or discomfort? Yes No DK Date of last dental x-rays Date of your last dental exam What was done at that time?What is the reason for your dental visit today?How do you feel about your smile?Medical InformationAre you now under the care of a physician? Yes No DK Physician namePhysician PhonePhysician Address Street Address City State / Province / Region ZIP / Postal Code Are you in good health? Yes No DK Has there been any change in your general health within the past year? Yes No DK If yes, what condition is being treated?Date of last physical exam? Have you had a serious illness, operation, or been hospitalized in the past 5 years? Yes No DK If yes, what was the illness or problem?Are you taking or have you recently taken any prescription or over the counter medicine(s)? Yes No DK If so, please list all, including vitamins, natural or herbal preparations and/or diet supplements:Do you wear contact lenses? Yes No DK Do you use controlled substances (drugs)? Yes No DK Do you use tobacco (smoking, snuff, chew, bidis)? Yes No DK If so, how interested are you in stopping? Very Somewhat Not Interested Do you drink alcoholic beverages? Yes No DK If yes, how much alcohol did you drink in the last 24 hours?If yes, how much alcohol do you typically drink in a week?Have you had an orthopedic total joint (hip, knee, elbow, finger) replacement? Yes No DK Date of joint replacement surgery If yes, have you had any complications?Are you taking or scheduled to begin taking either of the medications, alendronate (Fosamax®) or risedronate (Actonel®) for osteoporosis or Paget's disease? Yes No DK Since 2001, were you treated or are you presently scheduled to being treatment with the intravenous bisphosphonates (Aredia® or Zometa®) for bone pain, hypercalcemia or skeletal complications resulting from Paget's disease, multiple myeloma or metastatic cancer? Yes No DK Date treatment began Women OnlyAre you pregnant? Yes No DK Number of weeksAre you taking birth control or hormonal replacement? Yes No DK Are you nursing? Yes No DK AllergiesAre you allergic to or have had a reaction to any of the following:Local anesthetics Yes No DK Aspirin Yes No DK Penicillin or other antibiotics Yes No DK Barbiturates, sedatives, or sleeping pills Yes No DK Sulfa drugs Yes No DK Codeine or other narcotics Yes No DK Metals Yes No DK Latex (rubber) Yes No DK Iodine Yes No DK Hay fever/seasonal Yes No DK Animals Yes No DK Food Yes No DK Other Yes No DK To all YES responses above, please specify type of reaction:Please mark your response to indicate if you have or have not had any of the following diseases or problems.Artificial (prosthetic) heart valve Yes No DK Previous infective endocarditis Yes No DK Damaged valves in transplanted heart Yes No DK Congenital heart disease (CHD) Yes No DK Unrepaired, cyanotic CHD Yes No DK Repaired (completely) CHD in last 6 months Yes No DK Repaired CHD with residual effects Yes No DK Except for the conditions listed above, antibiotic prophylaxis is no longer recommended for any other form of CHD.Cardiovascular disease Yes No DK Angina Yes No DK Arteriosclerosis Yes No DK Congestive heart failure Yes No DK Damaged heart valves Yes No DK Heart attack Yes No DK Heart murmur Yes No DK Low blood pressure Yes No DK High bloog pressure Yes No DK Other congenital heart defects Yes No DK Mitral valve prolapse Yes No DK Pacemaker Yes No DK Rheumatic fever Yes No DK Rheumatic heart disease Yes No DK Abnormal bleeding Yes No DK Anemia Yes No DK Blood transfusion Yes No DK If yes, date of transfusion Hemophilia Yes No DK AIDS or HIV infection Yes No DK Arthritis Yes No DK Autoimmune disease Yes No DK Rheumatoid arthritis Yes No DK Systemic lupus erythematosus Yes No DK Asthma Yes No DK Bronchitis Yes No DK Emphysema Yes No DK Sinus trouble Yes No DK Tuberculosis Yes No DK Cancer/Chemotherapy/Radiation Treatment Yes No DK Chest pain upon exertion Yes No DK Chronic pain Yes No DK Diabetes Type I or II Yes No DK Eating disorder Yes No DK Malnutrition Yes No DK Gastrointestinal disease Yes No DK G.E. Reflux/persistent heartburn Yes No DK Ulcers Yes No DK Thyroid problems Yes No DK Stroke Yes No DK Glaucoma Yes No DK Hepatitis, jaundice or liver disease Yes No DK Epilepsy Yes No DK Fainting spells or seizures Yes No DK Neurological disorders Yes No DK If yes, specifiy neurological disordersMental health disorders Yes No DK If yes, specifiy mental health disordersRecurrent infections Yes No DK If yes, specifiy type of infectionSleep disorder Yes No DK Kidney problems Yes No DK Night sweats Yes No DK Osteoporosis Yes No DK Persistent swollen glands in neck Yes No DK Severe headaches/migraines Yes No DK Severe or rapid weight loss Yes No DK Sexually transmitted disease Yes No DK Excessive urination Yes No DK Has a physician or previous dentist recommended that you take antibiotics prior to your dental treatment? Yes No DK Name of physician or dentist making recommendationPhoneDo you have any disease, condition, or problem not listed above that you think I should know about? Yes No DK Please explainNOTE: Both Doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment. I certify that I have read and understand the above and that the information given on this form is accurate. I understand the importance of a truthful health history and that my dentist and his/her staff will rely on this information for treating me. I acknowledge that my questions, if any, about inquiries set forth above have been answered to my satisfaction. I will not hold my dentist, or any other member of his/her staff, responsible for any action they take or do not take because of errors or omissions that I may have made in the completion of this form.Signature of Patient/Legal GuardianDate FOR COMPLETION BY DENTISTComments This iframe contains the logic required to handle Ajax powered Gravity Forms.