Adult Personal & Health Questionnaire
All questions in this questionnaire are strictly confidential and become a part of your medical history.
Full Name:______________________________________ Sex: M or F D.O.B. _________ Age ____ SS#______-_____-_____
Home Address: (Street/City/State/Zip) ____________________________________________________________________________ Home Phone: _______________Work:_________________Mobile:
Marital Status: ____ (S/M/D/W) Spouse Name:___________________
How did you hear about our office? __________________________________ ________________________________________________________ Medical Hist
Have you ever been treated for the below: (Check those that apply)Yes/No Yes/ No Yes/ No Yes/ No Yes/ No
Endocrine Problems Prolonged Bleeding Hepatitis Diabetes Arthritis
Nervous Disorder Heart Problems Cancer Liver Problems Asthma
Rheumatic Fever Bone Disorder Fainting Birth Defects AIDS/HIV
Do you now or have you ever taken bisphosphonates, including Fosamax, Didronel, Boniva, Aredia, Actonel, Skelid, or
Zometa? ____ If so, which drug? _____________________
Do you have any disease, condition, or problem not listed that you think we should know about?
Please explain: _________________________________________________________________________________ Are you under the care of a physician? If yes why? ___________
Are you taking any medication at this time? Yes No If, yes, plea
se list: _________________________________________
Do you have any allergies? Yes No If, yes, please list:_______________________________________________________
Dental History TMJ History
Have there been any injuries to the face, mouth or teeth?
Do you have any problems with speech?
Do you have or have had any discomfort
Have you been informed of any missing permanent teeth?
Do you play a wind instrument? What Kind? ___________ Do you have pain or ringing in the ear?
Have you had any previous orthodontic exam or treatment? Are any teeth sore or sensitive?
Any cavities not filled? _____________ Has the jaw ever locked or slipped out of place?
Any gum problems? ________________
Do you have frequent headaches?
Your Dentist Name ______________________
Last Cleaning Date_______________________
How often do you brush? __________________
How often do you floss? ___________________Billing Party Information (if different from above)
Name:___________________________ Relationship to Patient:____________ Sex: M or F D.O.B.:_______________
Home Address: (Street/City/State/Zip) _____________________________________________________
Home Phone:_____________________ Work Phone:__________
Employer: ___________________ Occupation: ______________
__________No. of yrs Employed:__________________
Policy Holders Name:__________________________________ SSN: ____-___-______ Birth Date:_______________
Insurance Company: _________________________Policy ID#:_____________________ Group#:_________________
Insurance Company Address:__________________________________________________ Phone:________________
___________________ Employer Address:_____________________________________________________
Relationship to patient:____________________________________________________________________________
I understand that the information that I have given is correct to the best of my knowledge, that it will be held in the strictest of confidence and it is my responsibility to inform the office of any changes to child’s medical status. If this office accepts insurance, I understand that I am responsible for payment of any co-payment or deductibles or any fee that my insurance does not cover. Signature of Patient____________________________________________Date___________________
I have not found a source that chronicles the history of Jeffrey and his family. In order to fill this gap, this document was compiled from a variety of sources to provide a general chronology of the family’s life. In many cases, exact dates of events are not known, so approximate years/ There is a lack of agreement among the sources as to why Jeffrey was not attending school at the
Schweizerische KopfwehgesellschaftSociété Suisse pour l’étude des céphaléesSocietà Svizzera per lo studio delle cefaleeSocietad svizra per il studi del mal il tgauCet e brochure constitue une révision et une actualisa-tion des recommandations thérapeutiques de la Société Suisse pour l’étude des céphalées, recommandations qui ont fait leur preuve depuis de nombreuses années dans