Confidential Adult Patient Information
Date
Name (& Preferred name)
Sex
Age
Address
City:
State
Zip
How long at this address?
Own
Rent
Home phone
Work Phone
Cell phone
Cell Carrier
Has Dr. Hunt treated others in your family?
Name of that family member
E-mail address
Employer
Occupation
No. Years Employed
SSN#
Birthdate
Spouse’s Name (if applicable)
Employer
Occupation
No. Years Employed
SSN#
Birthdate
Cell phone
Dental Insurance Information
Policy Holder’s Name
ID# or SSN#
Insurance Company.
Group No.
Insurance Co. Address
Ins Phone #
Policy Holder’s Employer
Do you have dual coverage?
No
Yes
If Yes:
Policy Holder’s Name
ID# or SSN#
Insurance Company.
Group No.
Insurance Co. Address
Ins Phone #
Policy Holder’s Employer
I hereby assign insurance benefits to Dr. J. Todd Hunt
Signature of Patient
Your web browser does not support HTML5 Canvas. Signature object cannot be displayed.
Date Signed:
Medical History
What is your present health?
Good
Fair
Poor
Name of Family Physician
Last visit within one year?
Yes
No
Circle any of the following that you have had (past or present):
Heart disease
Liver problems or Hepatitis
HIV+ or AIDS
Artificial heart valve
Kidney problems
Cancer or tumors
Heart murmur
Diabetes
Cleft lip/palate
Rheumatic fever
Arthritis
Tonsils or Adenoids removed
Asthma
Bleeding problems
Speech or hearing problems
Epilepsy/Seizures
Others
Please list any:
Medications you’re presently taking
Medications you’re allergic to
Surgeries or emergency treatment you have undergone:
Do you smoke/vape?
Yes
No
Females: Are you pregnant now? (For X-ray purposes)
Yes
No
Dental History
Family Dentist
Whom may we thank for recommending our office?
Has the patient ever had any injuries to the jaws, mouth, or teeth?
Yes
No
If yes, explain
Circle any of the following that you have had (past or present):
Toothaches/sensitive teeth
Grinds or clenches teeth
Cavities
Jaw joint or muscle pain
Bleeding gums
Frequent headaches
Thumbsucking
Mouthbreathing or difficulty breathing through nose
What is your main reason for seeking this appointment?