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Adult Form

Patient
First Name Middle Name Last Name
Preferred Name Gender
Birth date Age Social Security Number
 
Patient's Contact Information
Street City State Zip
Phone E-mail address
 
If patient is a minor, give parent's or guardian's name.
 
How did you hear of our office?
 
Responsible Party Information
First Name Middle Name Last Name
Marital Status
Home Address City State Zip
Mailing Address City State Zip
Home Phone Work Phone
 
Birth Date Social Security Number
Relationship to Patient
 
Employer Occupation
Number of Years Employed
 
Closest relative not living with you to contact in case of an emergency
Name Phone
 
Insurance Information
Insured's Name Insured's Social Security #
Address
Home Phone Work Phone
Birth Date
Insured's Employer
Insurance Company Group Number Local Number
Insurance Company Address Insurance Phone Number
Do you have dual coverage? yes no
   

Medical History

 
Family Physician Physician's Phone Number
Date of Last Visit
 
   
Are you taking any medication? yes no
Have you had any major operations? yes no
Are you allergic to any medications? yes no
Have you ever been involved in a serious accident? yes no
Do you have a history of a major illness? yes no
   
Have you ever had any of the following diseases or medical problems
Abnormal Bleeding / Hemophilia yes no
Anemia yes no
Arthritis yes no
Asthma or Hayfever yes no
Bone Disorders yes no
Congenital Heart Defect yes no
Diabetes yes no
Dizziness yes no
Epilepsy yes no
Gastrointestinal Disorders yes no
Heart Problems yes no
Heart Murmur yes no
Hepatitis / Liver Problems yes no
Herpes yes no
High Blood Pressure yes no
HIV + / AIDS yes no
Kidney Problems yes no
Nervous Disorders yes no
Pneumonia yes no
Prolonged Bleeding yes no
Radiation / Chemotherapy yes no
Rheumatic Fever yes no
Tuberculosis yes no
Tumor or Cancer yes no
   
Patient Dental History  
General Dentist Date of Last Visit
Dentist Phone Number  
What concerns you most about your teeth?
Have you ever taken antibiotics before visiting your dentist? yes no
Are you presently in any dental pain? yes no
Have you ever experienced any unfavorable reaction to dentistry? yes no
Have you ever lost or chipped any teeth? yes no
Have there been any injuries to face, mouth or teeth? yes no
Is any part of your mouth sensitive to temperature or pressure? yes no
Do your gums bleed when you brush? yes no
Do you have any type of thumb or tongue habit? yes no
Are you a mouth breather? yes no
Are you taking any herbal supplements? yes no
Do your teeth or jaws ever feel uncomfortable when you awake in the morning? yes no
Are you aware of your jaw clicking or popping? yes no
Are you aware of clenching your teeth during the day? yes no
Have you ever been told that you grind your teeth? yes no
Do you have "tension" headaches? yes no
Have you ever experienced chronic ringing in your ears? yes no
Are you aware some appointments will be during school / work hours? yes no
 

The information processed with this form will be delivered to Seville Family Dentistry in a secure manner.

 

Seville Family Dentistry
3336 E. Chandler Heights Road
Building 3, Suite 119
Gilbert, AZ 85297

(480) 279-4790