Adult Medical History - Schellinck

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Services
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Patient Forms
Contact

Schedule Appointment

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Patient Medical History

Please fill out information below to the best of your ability.

Name

First Last

Email

Phone

Dentist’s Name

Approximate date of last radiographs (x-rays) exam

MM slash DD slash YYYY

Approximate date of last hygiene continuing care appointment

MM slash DD slash YYYY

If you left your previous dentist, what are the reasons?

Have you had problems with prior dental treatment?

Are you experiencing any pain now?(Required)

Yes

No

If yes, please describe

Have you been anxious about having dental treatment?(Required)

Yes

No

If yes, please explain

What concerns do you currently have with your oral health or smile?

Jaw joint pain

Clenching or grinding of teeth

Discolored teeth

Crowding/Crooked teeth

Missing teeth

Spaces in between teeth

Loose tooth/teeth

Tooth shape or size

Unhappy with appearance of teeth

Overbite

Underbite

Uncomfortable bite

Old fillings (gold or silver)

Old crowns

Speech problems

Too much gum tissue when I smile

Tooth sensitivity to hot/cold or anything else

Food gets caught in between teeth

Difficulty chewing

Bad breath

Other

Other

Have you ever had an orthodontic consult?(Required)

Yes

No

When?

MM slash DD slash YYYY

Have you ever had orthodontic treatment?(Required)

Yes

No

If yes, when?

Have you ever had periodontal (gum tissue) treatment, such as deep cleanings, root planing, or periodontal surgery?(Required)

Yes

No

If yes, when?

Have you ever whitened your teeth?(Required)

Yes

No

If yes, when?

Please list the main reason for this visit

What are your treatment goals and what would you like to accomplish?

I. Check Appropriate Answer

Is your general health good?(Required)

Yes

No

If NO, explain

Has there been a change in your health within the last year?(Required)

Yes

No

If YES, explain

Have you gone to the hospital or emergency room or had a serious illness in the last three years?(Required)

Yes

No

If YES, explain

Are you being treated by a physician now for a condition?(Required)

Yes

No

If YES, explain:

HAVE YOU EVER HAD OR DO YOU HAVE ANY OF THE FOLLOWING?

Heart disease

Family history of heart disease

Heart attack

AIDS/HIV

Surgeries

Hospitalization

Psychiatric care

Osteoporosis

Thyroid disease

Artificial joint

Diabetes

Asthma

Stomach problems or ulcers

Family history of diabetes

Hepatitis

Heart defects

Tumors or cancer

Sexual transmitted disease

Heart murmurs

Chemotherapy

Herpes

Rheumatic fever

Radiation

Canker or cold sores

Skin disease

Arthritis, rheumatism

Anemia

Hardening of arteries

Emphysema or other lung disease

Liver disease

High blood pressure

Kidney or bladder disease

Eye disease

Seizures

Stroke

Transplants

Cosmetic surgery

Eating disorders

Tuberculosis

Other

ARE YOU ALLERGIC TO OR HAVE YOU HAD A REACTION TO ANY OF THE FOLLOWING?

Aspirin

Valium or other sedatives

Codeine or other narcotics

Penicillin or other antibiotics

Latex

Foods

Nitrous oxide

Local anesthetic

Metal

Which Foods?

Other

ARE YOU TAKING OR HAVE YOU TAKEN ANY OF THE FOLLOWING IN THE LAST THREE MONTHS?

Recreational drugs

Tobacco in any form

Antibiotics

Over-the-counter medicines

Alcohol

Supplements

Weight loss medications

Bisphosphonate (Fosamax)

Aspirin

Anti-Depressants

Herbal supplements

Please list all prescription medications

WOMEN ONLY

Are you or could you be pregnant?

Are you nursing?

Do you have or have you had any other diseases or medical problems NOT listed on this form?(Required)

Yes

No

If YES, please explain

Patient or Guardian Signature(Required)

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1855 San Miguel Dr., Suite 14 Walnut Creek, CA 94596
Tues-Fri 8:00-5:00
925.300.3619

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