Adult Patient Form


Adult Patient Information
 





Date of birth
 
 

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Do you wish to receive appointment reminders?



 

Approximate date of last appointment?
 
 


Responsible Party Or Spouse
 





 
Primary Phone


Dental Insurance Information
 





Subscriber date of birth
 
 
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Subscriber date of birth
 
 
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Medical History
 


Last Visit
 
 
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Have your tonsils or adenoids been removed?



Have you experienced jaw joint pain/discomfort? (TMJ/TMD)?



Do you have missing or extra permanent teeth?



Have you had an injury to?




Have you had gum disease or periodontal treatment?



Have you ever taken medications for treatment of Osteoporosis? (Fosamax, Boniva, etc.)



Do you have any sensory processing issues?



(Women) Are you pregnant?



Do you have speech problems?



Do you have any of the following habits?










Do your gums bleed?



Do you like your smile?


 

 


Do you smoke or chew tobacco?


Emergency Contact
 




I understand that the information that I have provided is correct to the best of my knowledge, that it will be held to the strictest of confidence and it is my responsibility to inform this office of any changes in my medical status.

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