Adult Medical History Form

Complete and accurate information helps us tailor your care from the first appointment. Please fill out the form thoroughly so we can understand your medical history, dental needs, and preferences ahead of your visit. This will help ensure a smoother, more personalized experience.

Name*:

DOB*:

Address*:

Email*:

Indian Status #:

Emergency Contact*:

Phone*:

Insurance Information

Insurance Provider

Employer:

Occupation:

Policy #:

ID #:

Medical History

Have you been hospitalized within the last two years? If yes, what for?

Please list any and all of your current medications:

Please list your allergies if any:

Are you pregnant? If yes, how far along?

Do you have any of the following:

Heart Disease

Tuberculosis

High Blood Pressure

Cancer

Breathing Problems

Hepatitis

Diabetes

AIDS / HIV

Rheumatic Fever

Thyroid Problems

Chronic Headaches

Mental Health Concerns

Epilepsy

Fainting or Dizziness

Blood Disorder

Kidney Disease

Do you smoke?

Other

Do you have or have had:

Recession of gums

Uncomfortable bite

Bleeding gums

TMJ (jaw) problems

Bad breath

Neck or back pain

Frequent cavities

Orthodontics

Pain around the ears

Swelling in mouth

Clenching or grinding of teeth

Signature:

Date