Please Fill Out The Forms Only When The Appointment Is Scheduled.
New Patient Medical History
Please do not print the forms. Submit the forms online only.
Patient Name
*
First Name
Middle Name
Last Name
Medical History
Indicate which of the following you have had or have at present.
Allergies
Allergy - Aspirin
Allergy - Codeine
Allergy - Erythro
Allergy - Hay Fever
Allergy - Latex
Allergy - Other
Allergy - Penicillin
Allergy - Sulfa
Anemia
Arthritis
Artificial Joints
Asthma
Blood Disease
Cancer
Diabetes
Dizziness
Epilepsy
Excessive Bleeding
Fainting
Glaucoma
Head Injuries
Heart Disease
Heart Murmur
Hepatitis
High Blood Pressure
HIV
Jaundice
Kidney Disease
Liver Disease
Low Blood Pressure
Mental Disorders
MVP
Nervous Disorders
Other
Pacemaker
Pre-Med - Amox
Pre-Med - Clind
Pre-Med - Other
Radiation Treatment
Respiratory Problems
Rheumatic Fever
Rheumatism
Sinus Problems
Stomach Problems
Stroke
Thyroid Problem
Tuberculosis
Tumors
Ulcers
Venereal Disease
A smoker or smoked previously
Ever been hospitalized (illness or injury)
FEMALE: Pregnant
FEMALE: Taking birth control pill
Presently being treated for any other illnesses
Taking dietary supplements
Taking medication for weight control (ie fen-phen)
Subject to frequent headaches
If any condition or alerts selected above needs further clarification, Please Explain Below:
Please list any supplements you are currently taking
Do you take antibiotic premedication for your dental visits?
*
Yes
No
If Yes, Please Explain
*
Name of Physician and their Specialty
Most Recent Physical Exam and Purpose
Have you taken any medications within the last two years?
*
Yes
No
List all medications
*
Have you taken supplements, and/or vitamins within the last two years?
*
Yes
No
List all supplements and vitamins
*
Smile Characteristics, Check all the apply
Is there anything about the appearance of your teeth that you would like to change?
Have you ever whitened (bleached) your teeth?
Have you felt uncomfortable or self-conscious about the appearance of your teeth?
Have you been disappointed with the appearance of previous dental work?
Bite and Jaw Joint, Check all the apply
You have problems with your jaw joint
You have problems chewing
Your teeth changed in the last 5 years, become shorter, thinner, or worn
Your teeth are crowding or developing spaces
You chew ice, bite your nails, use your teeth to hold objects, or have any other oral habits
You clench your teeth in the daytime or make them sore
You have problems with sleep or wake up with an awareness of your teeth
You wear or have worn a bite appliance
Tooth structure, Check all the apply
Cavities within the past 3 years
The amount of saliva in your mouth seems too little or you have difficulty swallowing any food
You notice or have holes (i.e. pitting, crates) on the biting surface of your teeth
Any teeth sensitive to hot, cold, biting, sweets, or avoid brushing any part of your mouth
Grooves or notches on your teeth, chipped teeth, or had a toothache or cracked filling
Food gets caught between any teeth
Gum and Bone, Check all the apply
Gums bleed when brushing or flossing
Treated for gum disease or were told you have lost bone around your teeth
Noticed an unpleasant taste or odor in your mouth
History or periodontal disease in your family
Experienced gum recession
Had any teeth become loose on their own (without injury), or have difficulty eating an apple
Experienced a burning sensation in your mouth
If any of the checked boxes need further explanation, please describe
Signature
*
Patient Name
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Should be Empty: