New Patient Form

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First Name
Intial
Last Name
Home Address
Apt #
City
State
Zip
Home Phone
Cell Phone
Work Phone
DL#
Sex
Employer
Position
Employer Address
Employer Phone
In case of emergency, please contact
Phone

YOUR PRIVACY IS IMPORTANT TO US

How Would You Like Us To Communicate With You?

So that we are in compliance with HIPAA & the ADA, please check the box/boxes below giving consent to the dental practice or its service provider to contact you by mail, email, phone and/or text message regarding appointment reminders, information about treatments, payments, insurance, & other types of communication.

Please notify our office immediately if your contact information changes.

Check & Complete All That Apply (Please Print Clearly)

Contact me by Mail at the following address
Contact me by Email at the following address
Contact me by Text Message at the following number
Contact me by Phone at the following number/s:
Cell
Home
Work
Print Name
Date
Signature

HEALTH HISTORY

First Name
Middle Name
Last Name
Date
Chart #
Age
Sex
Height
Weight
IN CASE OF AN EMERGENCY, please contact (name/relation)
Phone #
INSTRUCTIONS: Answer all questions and fill in the blank spaces when indicated. Answers to the following questions are for our records only and will be kept confidential.
Why are you here today?
When was your last visit to a dental office?
When were your last x-rays taken?
Are those x-rays available?
If YES, please write down PRIOR DENTIST NAME and PHONE NUMBER.
1. Are you in poor health?
2. Has there been any change in your general health within the past year?
3. My last physical was on
4. Are you currently under the care of a physician?
If so, what is the condition being treated?
5. The name, address and phone number of my physician:
6. Have you had any serious illness or operation?
If so, what was the illness or operation?
7. Have you been hospitalized or had serious illness within the past five years?
If so, what was the problem?
8. Do you have or have you had any of the following diseases or problems:
A. Damaged heart valves or artificial heart valves
B. Congenital heart lesions or murmurs
C. Cardiovascular disease (heart trouble, heart attack, coronary insufficiency, coronary occlusion, high blood pressure, arteriosclerosis, stroke)
1) Do you have pain in the chest upon exertion
2) Are you ever short of breath after mild exercise
3) Do your ankles swell?
4) Do you get short of breath when you lie down, or do you require extra pillows when you sleep?
5) Do have a cardiac pacemaker?
D. Sinus trouble
E. Asthma
F. Allergy
G. Hives or skin rash
H. Fainting spells or seizures
I. Diabetes
1) Do you urinate (pass water) more than 6 times a day?
2) Are you thirsty much of the time?
3) Does your mouth frequently become dry?
J. Hepatitis, jaundice or liver disease
K. Arthritis
L. Inflammatory rheumatism (painful, swollen joints)
M. Stomach ulcers
N. Kidney trouble
O. Tuberculosis
P. Do you have a persistent cough or cough up blood
Q. Low blood pressure
R. Venereal disease
S. Do you have:
Others:
9. Have you had abnormal bleeding associated with previous extractions, surgery, or trauma?
A. Do you bruise easily?
B. Have you ever required a blood transfusion?
If so, explain the circumstances
10. Do you have any blood disorder such as anemia?
11. Have you had surgery or x-ray treatment for tumor, growth, or other condition of your mouth or lip?
12. Are you taking any of the following?
L. Other drug or medicine
13. Are you taking or scheduled to begin taking either of these medications?
14. Since 2001, were you treated or are you presently scheduled to begin treatment with the intravenous Biphosphonates (Aredia or Zometa ) for bone pain, Hypercalcemia or skeletal complications resulting from Paget’s Disease, Multiple Myeloma or Metastatic cancer?
Date treatment began:
15. Are you allergic or have you reacted adversely to any of the following?
Other allergies
16. Have you taken the diet medication Redux (Fen-Phen)?
17. Do you have any disease, condition, or problem not listed above that you think I should know about?
18. Are you employed in any situation which exposes you regularly to x-rays or other ionizing radiation?
19. Are you wearing contact lenses?
20. Have you ever had any of the following conditions?
21. Are you pregnant?
22. Do you have any problems associated with your menstrual period?
23. Are you nursing?
24. Have you had any serious trouble associated with any previous dental treatment?
If so, explain
25. How often do you brush your teeth?
26. Do you use dental floss?
27. Do your gums bleed or hurt?
How often?
28. Are any of your teeth sensitive to:
29. Does food get caught in your teeth?
30. Do you have frequent
31. Do you clench or grind your teeth?
32. Have you experienced any pain or soreness in the muscles of your face or around your ear?
33. Does your jaw click or pop?
I hereby certify that I have read the foregoing and have filled out this health questionnaire completely. I have advised you of all medical problems of which I am aware. I further certify that I, the undersigned, consent to the performing of x-rays and examination.
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SIGNATURE OF PATIENT OR GUARDIAN if patient is a minor X
DATE