blivaissdds - New Patient Form

Patient Contact Information

The following information is requested to assist the Doctor in administering the proper dental service.
Please answer the questions to the best of your ability.

Thank you for your cooperation.

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Area CodePhone Number

Home PhoneCell PhoneWork PhoneEmail

SingleMarriedWidowedDivorced

Emergency Contact Information

Format: (000) 000-0000.

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Area CodePhone Number

ExcellentGoodFairPoor

Rows	Yes	No
Have you had any radiological diagnostic x-rays in the last five years?
Have you had any blood transfusions?
Are you currently trying to modify your weight?
Do you take any medications to help in weight reduction?
Do you consume alcohol on a daily basis?
Have you experienced any recent weight change?

Do you have or have you ever been informed that you had any of the following :

Rows	Yes	No
Chest Pains
Heart Disease
Rheumatic Fever
Congenital Heart Defects
Heart Murmur
Postural Hypotension (fainting spells)
Hypertension
Kidney Problems
Stroke
Thyroid Problems
Hormonal Problems
Ulcers
Tuberculosis or Lung Disease
Diabetes
Epilepsy or Seizures
Anemia
Cancer or Leukemia
Psychiatric Problems
Sickle Cell Disease
Glaucoma
Prosthetic Valves or Joints

Rows	Yes	No
Bruise Easily
Jaundice
Asthma or Hay Fever
Allergies or Hives
Sinus Trouble
Arthritis
Excessive Urination and/or Thirst
Persistent Cough
Prolonged Bleeding Problems
Sexually transmitted diseases: (Gonorrhea. Syphilis. Genital Herpes
Genetic Problems
Skin Disease
AIDS
Unexplained Fevers
Prolonged Sore Throat
Enlarged Lymph Nodes
Night Sweats
Persistent Diarrhea
Bluish-Reddish Lesions
Fatigue
Covid 19

Rows	Yes	No
Have you ever been tested for Hepatitis?
Do you have a history of cold sores. fever blisters, or canker sores?
Are you being treated with immunosuppressive drugs?
Have you ever used drugs for recreational purposes?

Rows	Yes	No
Do you experience dry mouth (Xerostomia) ?
Do your gums feel tender or swollen?
Do your gums bleed while brushing and/or flossing?
Do you avoid brushing any part of your mouth because of pain or sensitivity?
Do you feel twinges of pain when your teeth come in contact with hot, cold, sweet or sour?
Are any of your teeth sensitive to air or during chewing?
Do you chew on only one side of your mouth?
Does food catch between your teeth'?
Do you feel your teeth are affecting your health in any way?
Have you ever had professional advice in dental home care?
Do you clench or grind your teeth while sleeping or during the day?
Do your facial muscles ever feel tired?
Do you have retention problems with your full or partial dentures?
Do you gag easily?

Nitrous OxideMedication prior to treatment

CONSENT:

The undersigned hereby authorizes the Doctor to perform all the necessary diagnostic procedures deemed appropriate to make a thorough diagnosis of the patients' dental or oral-facial needs including x-rays, study models, photographs, medications, and the use of local anesthetic agents.

Patient Contact Information

Emergency Contact Information

MEDICAL HISTORY

WOMEN

Do you have or have you ever been informed that you had any of the following :

DENTAL HEALTH

CONSENT: