Patient questionnaire for young adults 18 years and older Please enable JavaScript in your browser to complete this form.Patient Name *FirstLastPatient Date of Birth *Have you had a cough or fever in the past 2 weeks? *YesNoHave you been exposed to anyone in the past 2 weeks with fever and/or cough? *YesNoParent’s name and contact number if we need to call: *FirstLastAny dental problems? *YesNoPlease list your dental problems: *Any specific dental concerns? *YesNoPlease describe your dental concerns: *Any medical changes since last visit? *YesNoPlease explain medical changes: *Any recent hospitalizations? *YesNoPlease describe the reasons for your hospitalization: *Any medications? *YesNoPlease list your medications: *Change of address? *YesNoAddress *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeInsurance change? *YesNoPlease indicate your insurance, group number, subscriber’s DOB and ID: *Please upload a copy of the insurance card * Click or drag a file to this area to upload. Please upload a copy of your ID: * Click or drag a file to this area to upload. Signature *Clear SignatureBy signing, I acknowledge that all the information provided on this form is accurate and true to the best of my knowledge.CommentSubmit