Adkins Family & Cosmetic Dentistry

Welcome to Our Office!

Purpose of visit:

Whom may we thank for referring you to us?

Phone:

General Information

Home Phone: *

Work Phone:

Cell Phone:

Email:

If needed, may we contact you at the above phone numbers:

Home Work Cell

Patient Birth Date:

Soc. Sec. No:

Home Address:

Occupation:

Employer:

Business Address:

Name of Spouse:

Occupation of Spouse:

Spouse Work Phone:

Spouse Cell Phone:

Spouse Birth Date:

Spouse Soc. Sec. No:

Nearest relative not living with you:

Phone:

Emergency Contact Person:

Phone:

Emergency Contact Address:

Emergency Contact Relationship to Patient:

Guardian Name (if patient is a minor):

Medical History

Name of Physician:

City:

Phone:

Do you have any current medical problems?

Yes

No

If yes, please specify:

Are you now taking or using medicines for:

Diabetes (pills or shots) Nerves (tranquilizers, antidepressants, etc.)

Stomach trouble (ulcers, etc.) Heart or blood pressure

Blood (liver, iron pills, etc.) Allergies

Are you now:

Pregnant Using thyroid pills Using Dilantin

On a prescribed diet Using anticoagulants Using diet pills

Using antidepressants

Please list any other medications you are using:

Have you ever been sick from, shown an allergy to, or told not to take:

Antibiotics (please specify): Latex Allergy Codeine Aspirin Dental local anesthetics Other drugs or medicines (please specify):

Do you have any allergies not mentioned above?

Have you ever had a tumor or cancer?

Yes

No

Date of last radiation treatment:

If yes, please specify:

Have you ever had a major operation?

Yes

No

Year of operation:

If yes, please specify:

Have you ever been involved in a serious accident?

Yes

No

If yes, please describe:

Following injuries, have you ever had bleeding problems?

Yes

No

Do injuries and cuts take longer to heal now than previously?

Yes

No

Have you recently lost weight unintentionally?

Yes

No

Have you come to this office for relief of pain?

Yes

No

If yes, please specify:

Have you had the pain for more than two weeks?

Yes

No

Dental History

Previous Dentist:

City:

Phone:

Date of last dental exam:

Did you have a full mouth series of x-rays taken at your last dental exam?

Yes

No

Have you ever had orthodontic treatment?

Yes

No

Do your gums bleed when brushing or flossing your teeth?

Yes

No

Have you ever been told you have pyorrhea or periodontal disease?

Yes

No

Have you ever had professional instructions on dental home care?

Yes

No

Is any part of your mouth sensitive to temperature on pressure?

Yes

No

If so, where:

Does food catch between your teeth?

Yes

No

If so, where:

Do you have any unpleasant odor or taste in your mouth?

Yes

No

Do you have any pain or soreness around the eyes or ears?

Yes

No

Are you happy with the appearance of your teeth or your smile?

Yes

No

If no, please describe your "dream smile":

Occlusal Screening

Do you clench or grind your teeth during the day?

Yes

No

Do you clench or grind your teeth during the night?

Yes

No

Do you have chronic headaches?

Yes

No

Do you have chronic neck and shoulder pains?

Yes

No

Do you ever wake up feeling like your teeth/jaws have been under pressure?

Yes

No

Do the muscles in your neck or shoulder hurt?

Yes

No

Do you have a tight or stiff neck?

Yes

No

Have you ever had pain in your jaw joints or the sides of your face?

Yes

No

Do you have "clicking" jaw joints, "lock jaw" or limited jaw movement?

Yes

No

Which side of your mouth do you prefer to chew on?

Right

Left

Evenly on Both

Do we have permission to photograph your mouth and teeth?

Yes

No

Do we have permission to use your information in professional seminars or case studies?

Yes

No

Financial Information

Dental insurance company:

Insurance phone:

Subscriber name:

Subscriber birthdate:

Subscriber ID or Social Security No.:

Who is financially responsible for this account?

Medical insurance company:

Insurance phone:

Subscriber name:

Subscriber birthdate:

Subscriber ID or Social Security No.:

Who is financially responsible for this account?

If available, would you be interested in financing your dental treatment?

Yes

No

I will be paying today by:

Cash

Check

Credit Card

Adkins Family & Cosmetic Dentistry

Dr. Adkins' Dental Information Center

Patient Health History Form

Welcome to Our Office!

General Information

Medical History

Dental History

Occlusal Screening

Financial Information