New Patient Form

PERSONAL INFORMATION

Person responsible for the accountSelfOther

Dental Insurance:YesNo

Medical Alert

1. Are you now under the care of a physician? YesNo

2. Have you had any serious illness or operation. Have you ever been hospitalized?YesNo

3. Are you taking any drugs or medications, vitamins or supplements?YesNo

4. Are you allergic or have you had an adverse reaction to any medication such as antibiotics, pain killers, local anesthetic, etc.YesNo

a) Rheumatic fever or rheumatic heart disease?YesNo

b) Heart murmur? YesNo

c) Artificial heart valve? YesNo

d) Congenital heart lesions? YesNo

e) Cardiovascular disease (e.g. heart trouble, heart attack, high blood pressure, hardening of the arteries, stroke?) YesNo

f) Do you experience shortness of breath or chest pains when taking a walk or climbing stairs? YesNo

g) Asthma, hay fever, skin rash, or allergies? YesNo

h) Fainting spells or seizures (e.g. epilepsy)? YesNo

i) Nervous disorders? YesNo

j) Kidney disease or disorders? YesNo

k) Hepatitis, jaundice, or liver disease? YesNo

l) Endocrine disorders: e.g. thyroid disease? YesNo

m) Diabetes? YesNo

n) Glaucoma? YesNo

o) Lung or breathing disorders? e.g. tuberculosis. YesNo

p) Gastrointestinal disease? e.g. ulcers YesNo

q) Bone, muscle, or joint disorders? e.g. arthritis. YesNo

r) Cancer? YesNo

s) Radiation or x-ray therapy? YesNo

t) Corticosteroid or steroid therapy? YesNo

u) Artificial joints? YesNo

v) Organ transplant or other medical implant? e.g. A/V shunt. YesNo

w) Venereal disease? YesNo

6. Have you ever had abnormal bleeding associated with previous extractions, surgery, or trauma?YesNo

7. Do you bruise easily?YesNo

8. Do you have any blood disorder?YesNo

9. Women Are you pregnant?YesNo

10. Do you have any other disease or problem not listed above you think we should know about?YesNo

2. Is there a dental problem you would like to have taken care of as soon as possible? YesNo

3. Have you been given oral hygiene instruction? YesNo

4. Have you ever had local anesthetic? YesNo

5. Are your teeth sensitive? YesNo

6. Do your gums bleed? YesNo

7. Are your gums swollen and tender? YesNo

8. Does food catch between your teeth? YesNo

9. Are you aware of any loose teeth?YesNo

10. Do you object to dental x-rays?YesNo

11. Does your jaw crack, pop or grate?YesNo

12. Do you grind or clench your teeth?YesNo

13. Are you concerned with the overall appearance of your teeth? YesNo

14. Do you like your smile?YesNo

15. Is there anything else you would like to change about your front or back teeth?YesNo