Adult Health History

Adult Health History Form

Patient Information
Patient Name*
First Middle Last Suffix
Birth Date*
MM slash DD slash YYYY
Age*
Sex*
- Male
- Female
Address*
Street Address Address Line 2 City State ZIP Code
Phone*
Email*
Social Security Number*

Format: 123-45-6789
Driver's License Number*
Marital Status
- Single
- Married
- Divorced
- Widow
Employer
Street Address Address Line 2 City State ZIP Code
Occupation
Work Phone #
Full-Time Student?
- Yes
- No
If patient is minor we need: Mother’s Name & Birthdate, Father’s Name & Birthdate
Person Responsible for Account*
Name of Spouse (or parent if minor)*
First Last
Spouse's Employer (or parent's if minor)
Spouse's Work Phone (or parent's if minor)
Spouse's Social Security Number (or parent's if minor)

Format: 123-45-6789
Emergency Contact (someone not living with you)*
First Last
Emergency Contact's Address (someone not living with you)*
Street Address Address Line 2 City State ZIP Code
Emergency Contact's Phone # (someone not living with you)*
How did you hear about our office? (Check all that apply)
- Neighborhood Magazine (please specify below)
- Community Event Booth (please specify below)
- Family/Friend (please specify below)
- Direct Mailer
- Style Magazine
- Yelp
- Google
- B4the Movie
- Harris Center
- Social Media
- Folsom Sports Media
Specify Here:
Please state the reason for your visit:*
Dental Insurance Information (primary carrier)
Insured's Name*
First Middle Last Suffix
Insured's Date of Birth*
MM slash DD slash YYYY
Insured's Social Security Number*

Format: 123-45-6789
Insured's Employer*
Insurance Co.*
Insurance Co. Address*
Street Address Address Line 2 City State ZIP Code
Insurance Co. Phone*
Group #*
Policy #*
Dental Insurance Information (If you have a dual insurance coverage, complete this for the second coverage)
Insured's Name
First Middle Last Suffix
Insured's Date of Birth
MM slash DD slash YYYY
Insured's Social Security Number

Format: 123-45-6789
Insured's Employer
Insurance Co.
Insurance Co. Address
Street Address Address Line 2 City State ZIP Code
Insurance Co. Phone
Group #
Policy #
Dental History
Please check any of the following that apply to you:
- Headaches, ear aches, neck or jaw joint pain
- Mouth ulcers or cold sores
- Teeth or fillings breaking
- Grinding or clenching teeth
- Bleeding, swollen or irritated gums
- Loose, tipped or shifting teeth
- Bad breath
- Sensitivity (hot, cold, sweet)
Where?
Do you have or have you had any of the following? (check all that apply)
- Dentures
- Partial Dentures
- Braces
- Gum Treatments
If you could whiten your teeth for a cost anyone could afford, would you do it?
- Yes
- No
Do you smoke, use chewing tobacco, or vape?
- Yes
- No
How Much?
For How Long?
If I could change my smile, I would (check all that apply):
- Make my teeth whiter
- Make my teeth straighter
- Close spaces
- Replace metal fillings with tooth colored restorations
- Repair chipped teeth
- Replace missing teeth
- Replace old crowns that don’t match
- Have a smile makeover
Date of Last Cleaning
MM slash DD slash YYYY
Date of Last Oral Cancer Screening
MM slash DD slash YYYY
Date of Last Oral Cancer Screening
MM slash DD slash YYYY
On a scale of 1-10, with 10 being the highest, how important is your dental health to you?
On a scale of 1-10, with 10 being the highest, where would you rate your current dental health?
Name of Previous Dentist
Address
City State
Phone
Why did you leave your previous dentist?
What is the most important thing to you about your future smile and dental health?
What is the most important thing to you about your dental visit today?
Medical History
Please check any of the following that apply to you:
- Allergies (seasonal)
- Anemia
- Artificial Heart Valve
- Artificial Joints
- Asthma
- Blood Disease
- Bruise Easily
- Cancer
- Chemotherapy
- Diabetes
- Dizziness/Fainting
- Drug Addiction
- Emphasyma
- Excessive Bleeding
- Glaucoma
- Heart Conditions
- Heart Murmur
- Hepatitis A
- Hepatitis B
- Hepatitis C
- High Blood Pressure
- HIV/AIDS
- Jaundice
- Kidney Disease
- Liver Disease
- Mitral Valve Prolapse
- Nervousness/Depression
- Pacemaker
- Phen Fen (1 month +)
- Radiation (head/neck)
- Respiratory Problems
- Rheumatic Fever
- Rheumatism
- Scarlet Fever
- Seizures
- Stomach Problems
- Stroke
- Thyroid Disease
- Tuberculosis
- Ulcers
- Snoring
- Sleep Apnea
- Fatigue
- Migraines
- Chronic Pain
- Bisphosphonate
Other (please list):
For WOMEN Only (check all that apply):
- Birth Control Pills
- Breast Feeding
- Pregnant (1-3 months)
- Pregnant (4-6 months)
- Pregnant (7-9 months)
Do you have an allergy to any of the following? (check all that apply):
- Aspirin
- Erythromycin
- Latex
- Local Anesthetic
- Nitrous Oxide
- Penicillin
- Codeine
Other (please list):
What other medications are you currently taking?
Are you under a physicians care? For what?
Family Physician
First Last
Phone
Patient Signature
By typing your name below you are acknowledging that the above information is correct to the best of your knowledge and it is for use to help the professionals at Hammond & Proctor
Patient Signature (or Parent of Child)*
First Last
Date*
MM slash DD slash YYYY
I consent to the dental practice using my cell phone number to call or text regarding appointments and to call regarding treatment, insurance and my account. I understand that I can withdraw my consent at any time.*
- Call
- Text
Choose one or both
My cell phone number is (include area code)*
Initials*

Adult Health History Form

Patient Information

Dental Insurance Information (primary carrier)

Dental Insurance Information (If you have a dual insurance coverage, complete this for the second coverage)

Dental History

Medical History

Patient Signature