Campbell Ortho

Adult History Form

We would like to welcome you to our office. In an effort to provide the best service possible, we ask you to fill this form as completely as possible. Thank you for your cooperation.

Patient Information

Spouse Information

General Information

Insurance Information

Primary Insurance

Secondary Insurance

Emergency Contact Information

Dental History

Do you like your smile
Do you floss your teeth daily?
Have you ever had a serious problem with any prior dental work
Do you have any missing or extra permanent teeth?
Have there been any:
Have there been any injuries to the face, mouth, teeth, or chin?
Jaw joint pain
Popping/Clicking jaw joints?
Tightness in jaw joints?
Jaws tired during meals
Severe/Frequent headaches

Medical History

Allergies

Are you allergic to any of the following :
Aspirin
Any metal such as Nickel
Codeine
Dental anesthetics
Erythromycin
Latex
Penicillin
Tetracycline
Any Plastics

History Continued

Do any of the following apply to you? :
Anemia or Radiation treatment
Artificial Bones or Joints
Artificial Valves
Arthritis
Asthma
Bleeding disorder
Blood transfusing
Cancer/Chemotherapy
Congenital heart defect
Diabetes
Difficulty breathing
Drug or Alcohol abuse
Emphysema
Epilepsy or Seizures
Fever Blisters or Herpes?
Glaucoma
Handicap or Disability
Heart attack or stroke
Heart murmur
Heart Surgery or Pacemaker
Hemophilia
Hepatitis
High or Low blood pressure
HIV or AIDS
Hospitalization
Kidney or Liver problems
Mitral valve prolapse
Psychiatric or Mental problems
Rheumatic or Scarlet fever
Shingles
Sinus problems
Tuberculosis

Please Read and Sign Below

The information that I have provided is correct to the best of my knowledge. I understand that it is my responsibility to inform this practice of any changes in my medical status. I also understand that this practice reserves the right to verify the credit status (obtain a report) of any potential responsible party.

Verification

Please click on the human verification checkbox before submitting your form.