Adult Medical Health History Form printable pdf download

Adult Medical History

Account #________________

Name ____________________________________________________

S.S. #:____________________

Date of Birth:___________________ Sex: F M

Height:__________ Weight:____________

Race: _________________ Ethnicity:___________________Language Preference:_________________

General Health: [ ] Excellent

[ ] Good

[ ] Fair

Name of Physician

__________________________

Date of Last Physical ______________

Are you taking any Aspirin daily? [ ] Y [ ] N

Are you taking Coumadin, Plavix or any other blood thinner? [ ] Y [ ] N

Have you taken any steroids or cortisone in the past year? [ ] Y [ ] N

Are you taking any other medications? [ ] Y [ ] N

List medications: _______________________________________________________________

Please Check ALL that apply:

[ ] Abnormal blood pressure _____/______

[ ] HIV

[ ] Anemia/blood disorders

[ ] Hospitalizations SURGERY OR OVERNIGHT

[ ] Arthritis

[ ] Prescription diet pills

[ ] Asthma

[ ] Prolonged Bleeding

[ ] Blood Transfusion

[ ] Prosthetic Joint Replacement

[ ] Cancer

[ ] Rheumatic Fever

[ ] Diabetes

[ ] Sexually Transmitted Disease

[ ] Epilepsy

[ ] Sinus Trouble

[ ] Fainting Spells

[ ] Stroke

[ ] Glaucoma

[ ] Tuberculosis/Lung Disease

[ ] Heart Condition

[ ] Ulcers

[ ] Heart Surgery

[ ] Other ___________________________

[ ] Hepatitis

Allergies: [ ] Codeine

[ ] Jewelry/Metal

[ ] Latex

[ ] Novocaine [ ] Penicillin

[ ] Other ______________________________________________________

Women: Are you pregnant [ ] Y

[ ] N If Yes # of weeks:_______________________

Name of OB/GYN: ______________________________________________________

DENTAL HEALTH:

Date of last Dental Exam __________________Date of last Dental Cleaning ____________________

How often do you brush? __________________ Do your gums bleed when you brush? [ ] Y [ ] N

How often do you floss? ___________________Do you smoke? [ ] Y [ ] N if yes, how much _________

What kind of toothbrush do you use? [ ] Soft [ ] Medium [ ] Hard

Please Check all that apply:

[ ] Bleeding/tender gums

[ ] Wear Dentures

[ ] Clench/Grind teeth

[ ] Wear Partials

[ ] Gag easily

[ ] Wear Nightguard

[ ] Jaw/TMJ pain

[ ] Other______________________

[ ] Sensitive teeth (hot/cold/sweets)

EXAMINATION AND X-RAYS I understand that the examination visits may require

radiographs and diagnostic photos in order to complete the examination, diagnosis, and

treatment plan.

Signature: __________________________________________ Date: ___________________

Adult Medical Health History Form

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