Adult Health History Patient Name Birthdate Street Address City Occupation Home Phone Cell Phone Email Preferred method of appointment confirmations: PhoneTextEmail Emergency Contact Name and Relationship Emergency Contact Phone Dental & Medical History How do you feel about going to the dentist? PleasantNot too badDifficult, but I do okayTerrifying Specific concerns today? Last dental exam or cleaning? Anything you want to change about your smile? Primary Care Provider (Name & Phone) Under physician’s care currently? YesNo Hospitalized or major operation? YesNo Head or neck injury? If yes, when? Medications or supplements? Need to pre-medicate before dental visits? YesNo Pre-medicate due to dental anxiety? YesNo Taken Phen-Fen or Redux? YesNo Taken bisphosphonates (e.g. Fosamax, Boniva)? Special diet? YesNo Tobacco use? YesNo If yes, type and frequency Controlled substances use? What and how often? Are you: Pregnant/TryingNursingOn Oral Contraceptives Allergies Check any of the following allergies: AcetaminophenAcrylicAspirinBarbiturates/SedativesBee stingsCodeine/NarcoticsIbuprofenIodineLatexLocal AnestheticsMetalsPenicillin/AmoxicillinSulfa Drugs Other allergies: No known allergies Health History Please check any condition that applies: AIDS/HIV PositiveAlzheimer’s DiseaseAnaphylaxisAnemiaAnginaArthritisArtificial Heart ValveArtificial JointAcid Reflux/GERDAsthmaBlood DiseaseBlood TransfusionBruise EasilyCancerChemotherapyChest PainsCOPDCold Sores/Fever BlistersCongenital Heart DisorderCortisone MedicineDementiaDiabetes (Type I or II)Drug AddictionEasily WindedEmphysemaEpilepsy or SeizuresExcessive BleedingExcessive ThirstFainting Spells/DizzinessFrequent CoughFrequent HeadachesGlaucomaGoutHeart Attack/FailureHeart MurmurHeart PacemakerHeart Trouble/DiseaseHemophiliaHepatitis (A, B, or C)HerpesHigh Blood PressureHigh CholesterolHives or RashHypoglycemiaIrregular HeartbeatKidney ProblemsLeukemiaLiver DiseaseLow Blood PressureLung DiseaseMemory IssuesMitral Valve ProlapseMultiple SclerosisOsteopeniaOsteoporosisPain in Jaw JointsParathyroid DiseaseParkinson’s DiseasePost-Traumatic Stress Disorder (PTSD)Psychiatric CareRadiation TreatmentsRecent Weight LossRenal DialysisRheumatismShinglesSickle Cell DiseaseSinus TroubleSleep ApneaStomach/Intestinal DiseaseStrokeSwelling of LimbsThyroid DiseaseUlcersYellow JaundiceOther Other or Comments: Financial Policy Acknowledgement I understand that payment is due at time of service unless insurance arrangements have been made. I agree to the financial policy terms. I will: Pay at time of serviceUse insurance and pay remaining balance Consent I give permission for treatment and authorize the staff of Uptown Dental Clinic to proceed with necessary procedures. I understand the risks and responsibilities outlined. Signature: Date:
