New Patient Adult Dental Health History
Personal Information
Full Name
Date of Birth
Address
Phone Number
Email
Emergency Contact
Name
Phone
Relationship
Dental History
Sensitive Teeth
Bleeding Gums
Jaw Pain
Teeth Grinding
Bad Breath
Mouth Sores
Other
If other, please specify
Date of Last Dental Visit
Reason for Last Visit
Medical History
Are you under a physician’s care?
Yes
No
If yes, please explain
List any current medications
List any allergies
Please check if you have or had any of the following
Heart Disease
Diabetes
High Blood Pressure
Asthma
Epilepsy
Cancer
Other
If other, please specify
Habits
Tobacco Use
Yes
No
Alcohol Use
Yes
No
Other habits (describe)
Additional Information
Please include any other information you feel is important