Adult Patient Form

Patient Information and Health History

Patient’s Name
Date of Birth
Status
Patient Address
Phone
City
State
Zip
Cell/Other Phone
Person Responsible For This Account
Person Responsible Address
Person Responsible Phone
Person Responsible Employer
Person Responsible Business Phone
Dental Insuarnce Plan (if any)
Referred By
Chief Oral Complaint
Date of Last Oral Exam
Any Major Previous Major Dental Treatment
When?
In case of emergency contact

Do You Have, Have Had or Use Any of the Following

Teeth sensitive to cold, heat, sweets or pressure
Bleeding gums
How long?
Food impaction
Clenching or grinding
Frequent Blisters on lips or mouth
Mouth breathing
Bad breath
Unpleasant taste
Unfavorable dental experience
Complications from extraction
Periodontal treatment (Gum treatment)
Orthodontic treatment (Braces)
Cigarettes, pipe or cigar smoking
How much?
Spit tobacco
How often?
Frequency of brushing
How often?
Dental floss
Oral habits, ie. fingernail biting, cheeck biting, etc…

Medical History

Physician’s Name
Date of Last Physical Exam
Age
Allergies to drugs
Which Drugs?
Allergies to Anesthetics
Any heart ailment
Which Ailment?
High Blood Presure
Neurological problems
Radiation treatments
Excessive bleeding from cut or extraction
Anemia or blood problems
Chemotherapy
Chronic Fatigue Syndrom
Asthma/Respitory problems
Dental anxiety
Diabetes
Kidney problems
Liver problems or hepatitis
Malignancies
Psychiatric care/emotional problems
Seizures
Sinus problem
Immune system disorders (AIDS, HIV, ARC)
Stroke
Thyroid
Artifical Joints
Latex sensitivity
TB
Ulcer or colitis
Preganancy
If so, what month?
Medications for thinning of bones
Blood/bleeding disorder
Other
Other Description
Describe any current medical treatment including drugs taken, even though not listed above
Other continued…

Medical History Summary

Existing Illnesses
Existing Illnesses
Current Drugs
Current Drugs
Allergies
Allergies
Nutruional Eval
Nutruional Eval

Dental History Summary

Chief Complaint
Chief Complaint
Oral Habits
Oral Habits
Hygiene
Hygiene

Tests

Percussion
Pulse
Vitality
Other
Other 2
Other 3
Thermal
Blood Pressure
Syst
Dias

Dental Oro – Facial Exam

General Condition of Teeth
Gingiva & Periodontium
Gingiva & Periodontium 2
Gingiva & Periodontium 3
(a) Plaque
(b) Calculus
(c) Bleeding
(d) Recession
(e) Other
Occlusion & Functional Relations Midline
Class
Overjet
Overbite
Abnormalities
Summary of Dental Oro-Facial Exam
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Referral to Specialists
Referral to Specialists 2
Referral to Specialists 3

Treatment Plan

Treatment Plan for
Examination
XRays
Study Models
Other
Scaling
Prophylaxis
Flouride Treatment
Alloy Restoration:
Plastic Restoration
Other Restoration:
Full or Partial Coverage
Prostetic Replacement
Prostetic Replacement 2
Prostetic Replacement 3
Prostetic Replacement 4
Prostetic Replacement 5
Root Canal Therapy
Surgery & Extractions
Periodontics
Miscellaneous or Revisions in Treatment Plan
Misc. Continued…
Misc. Continued…
Misc. Continued…
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Misc. Continued…
Misc. Continued…