Dr. Cruz Adult Health History Form

Adult Health History Form
About you
Today's Date

MonthDayYear
Date
Email Address :
example@example.com
Patient Name :

First NameMiddle NameLast Name
I prefer to be called :
Gender :
Birthday :

MonthDayYear
Date
Age:
Social Security #:
Marital Status :
Home Address:

Street Address

Street Address Line 2

CityState

Zip Code
Cell #:
Format: (000) 000-0000.
Home Phone #:
Format: (000) 000-0000.
Work Phone #:
Format: (000) 000-0000 - Ext.
Where & when are best times to reach you?
Whom may we Thank for referring you?
Other family members seen by us :
Employment
Employer:
How long there?
Occupation
Employer's address:

Street Address

Street Address Line 2

CityState

Zip Code
Neighbor or Relative not living with you
His/Her Name
Relation
Address:

Street Address

Street Address Line 2

CityState

Zip Code
Home phone #:
Format: (000) 000-0000.
Work phone #:
Format: (000) 000-0000.
Person Responsible for Account if other then yourself
His/Her Name
Relation
Social Security #:
Employer:
Contact #:
Format: (000) 000-0000 - Ext 000.
Driving License
Billing address:

Street Address

Street Address Line 2

CityState

Zip Code
Spouse Information
His/Her Name
Birthdday

MonthDayYear
Date
Social Security #:
Employer:
Contact #:
Format: (000) 000-0000 - Ext 000.
Driving License
Address:

Street Address

Street Address Line 2

CityState

Zip Code
Insurance information
Primary insurance
Dental Coverage?
Medical Coverage?
Orthodontic Coverage
Insurance Co. name:
Insurance Co. Address :

Street Address

Street Address Line 2

CityState

Zip Code
Phone:
Format: (000) 000-0000.
Group# (Plan, Local or Policy#):
Insured’s Name :
Insured’s Social Security # :
Insured’s Birthday :

MonthDayYear
Date
Relation:
Insured’s Employer :
Employer's Address :

Street Address

Street Address Line 2

CityState

Zip Code
Secondary insurance
Dental Coverage?
Medical Coverage?
Orthodontic Coverage
Insurance Co. name:
Insurance Co. Address :

Street Address

Street Address Line 2

CityState

Zip Code
Phone:
Format: (000) 000-0000.
Group# (Plan, Local or Policy#):
Insured’s Name :
Insured’s Social Security # :
Insured’s Birthday :

MonthDayYear
Date
Relation:
Insured’s Employer :
Employer's Address :

Street Address

Street Address Line 2

CityState

Zip Code
Dental History
Why have you come to the dentist today?
Are you currently in pain
Do you require antibiotics before dental treatment?
Have you experienced problems associated with any previous dental work?
Do you now or have you ever experienced pain or discomfort in you jaw joint (TMD/TMJ)?
Your current dental health is:
Do you floss daily?
Brush daily?
Type of bristles on your toothbrush
How long do you use a toothbrush before replacing it
"Do you use anything in addition to your brush or floss"
If Yes, what?
Would you like fresher breath?
Whiter teeth?
Do your gums ever bleed?
Ever itch?
Have you ever had Periodontal disease?
Do you have mobility in your teeth?
Are your teeth sensitive to heat, cold or anything else?
Do you still have wisdom teeth
If Yes, why?
Previous/Present Dentist
Date of last visit:

MonthDayYear
Date
Reason for leaving your last dentist?
Are you happy with the way your teeth look and feel?
If not, what would you change?
Medical History
Do you have a personal physician?
Physician’s Name :
Phone #:
Format: (000) 000-0000.
Date of last visit :

MonthDayYear
Date
Physician’s Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Your current physical health is :
Are you currently under the care of a physician?
Please explain :
Have you ever taken Fosamax, or any other bisphosphonate?
Have you ever been told that you snore or hold your breath while sleeping or wake up gasping for breath?
Do you smoke or use tobacco in any other form?
For Women
Are you taking birth control pills?
Are you pregnant ?
Week # :
Are you nursing ?
Are you allergic to any of the following?

Other
Are you taking any of the following?
Have you ever taken Phen-Fen along known as Redux or Pondimin?
Are you taking any prescription/over-the-counter drugs not listed above?
If Yes, please list each one
Have you experienced the following?
Please list any other serious medical condition(s) that you have ever had :
I affirm that the information I have given is correct to the best of my knowledge. It will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my medical status. I authorize the dental staff to perform the necessary dental services I may need.
I understand that I am responsible for the payment of all services rendered.
Patient Signature
Date :

MonthDayYear
Date
Should be Empty:

Adult Health History Form

About you

Employment

Neighbor or Relative not living with you

Person Responsible for Account if other then yourself

Spouse Information

Insurance information

Primary insurance

Secondary insurance

Dental History

Medical History