whiterosefamilydental.com - New Patient Medical History

New Patient Information
About You
Name

First NameMiddle NameLast Name
Date of Birth:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Email:
example@example.com
Social Security #:
Home Phone:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Cell Phone:
Please enter a valid phone number.Format: (000) 000-0000.
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employer:
Occupation:
Work Phone:
Please enter a valid phone number.Format: (000) 000-0000.
Employer’s Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Is Patient Covered by Dental Insurance:
Name of Insurance Company:
Group #
Member ID
Emergency Contact:
Emergency Contact Phone:
Please enter a valid phone number.Format: (000) 000-0000.
How did you hear about our office?

Referral (Name of Individual who referred you)
Name of Spouse:
Spouse’s Date of Birth:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Spouse’s Occupation:
Spouse’s Email:
example@example.com
Spouse’s Cell Phone:
Please enter a valid phone number.Format: (000) 000-0000.
Spouse’s Employer:
Person Responsible for Account if Other than Patient
Name:
Relation to Patient:
Phone:
Please enter a valid phone number.Format: (000) 000-0000.
Date of Birth:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Social Security #:
Email:
example@example.com
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employer:
Occupation:
Work Phone:
Please enter a valid phone number.Format: (000) 000-0000.
Employer’s Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name of Insurance Company:
Group #
Member ID
Dental History
Reason for today’s visit:
Date of last dental care:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Former Dentist:
Date of last dental X-rays:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How often do you floss?
How often do you brush?
Any swelling or lumps in your mouth?
How do you feel about the appearance of your teeth?
Is your home water supply fluoridated?
Have you had any serious problems associated with any previous dental treatment?
Health/Medical History
Patient’s Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Height
Weight
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Answer all questions by choosing Yes or No . All responses are kept confidential.
1. Are you in good health?
2. Has there been any changes in your general health in the past year?
3. Date of last physical exam

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
4. Are you now under a physician’s care for a particular problem?
5. Have you ever had any serious illnesses, operations or hospitalization?
If so, describe
6. Sleeping disorder
7. DO YOU HAVE OR HAVE YOU EVER HAD:
A. Congenital Heart Disease, Unrepaired cyanotic CHD, Repaired (completely) in last 6 months, Repaired CHD with residual defects?
B. Cardiovascular Disease (Heart Attack, Heart Trouble, Heart Murmur, Coronary Artery Disease, Angina, High Blood Pressure, Stroke, Palpitations, Heart Surgery, Pacemaker)?
C. Artificial heart valves, Previous infective endocarditis, Damaged valves in transplanted heart, artificial joints (hip/knee replacement, etc.)?
D. Lung Disease (Asthma, Emphysema, COPD, Chronic Cough, Bronchitis, Pneumonia, Tuberculosis, Shortness of Breath, Chest Pain, Severe Coughing)?
E. Seizures, Convulsions, Epilepsy, Fainting or Dizziness?
F. Bleeding Disorder, Anemia, Bleeding Tendency, Blood Transfusion? Do you Bruise easily?
G. Liver Disease (Jaundice, Hepatitis)
H. Kidney Disease?
I. Diabetes?
J. Thyroid Disease (Goiter)?
K. Arthritis?
L. Stomach Ulcers or Colitis?
M. Glaucoma?
N. Osteoporosis?
O. Clicking or popping of jaw joint, pain near ear, or difficulty opening mouth?
P. Clench or grind your teeth?
Q. Sinus or Nasal problems?
R. Any disease, drug or transplant operation that has depressed your immune system?
S. HIV / AIDS?
T. Cancer/Chemotherapy/Radiation Treatment
8. Medications
A. Are you taking or have you ever taken Bisphosphonates for osteoporosis, Paget’s disease, multiple myeloma, or other cancers (Reclast, Fosamax, Actonel, Boniva, Aredia, Zomeata)?
B. Please list any and all medications taken, including prescription medications, diet drugs, over-the-counter medication, herbal or holistic remedies, vitamins or minerals
9. ARE YOU ALLERGIC TO OR HAVE YOU HAD AN ADVERSE REACTION to:
A. Local Anesthesia (Novacain, etc) ?
B. Penicillin or other antibiotics?
C. Aspirin or Ibuprofen?
D. Codeine or other pain killers?
E. Latex or Rubber products?
F. Sedatives?
G. Metal or any kind?
H. Chemicals or Jewelry (rash or sensitivity)?
I. Food products?
J. Other allergies or reactions? Please list
10. Do you smoke or chew Tobacco?
How much per day
11. Is there any past history of Alcohol or Chemical Dependency or Emotional Disorder that may affect the care we provide you?
12. Do you have any other disease, condition or problem not listed above that you think the doctor should know about?
13. FOR WOMEN ONLY
A. Are you pregnant, or is there any chance you might be Pregnant?
B. Are you nursing?
C. If you are using Oral Contraceptives. If is important that you understand that antibiotics (and some other medications) may interfere with the effectiveness of oral, contraceptives. Please consult with your physician for further guidance.
I understand the importance of a truthful and complete Health History to assist may dentist in providing the best care possible. I have had the opportunity to discuss my Health History with my dentist.
Signature of Person Completing Health History
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Doctor's Signature
Our office is HIPAA compliant and is committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC, and the ADA.
Should be Empty:

New Patient Information

About You

Person Responsible for Account if Other than Patient

Dental History

Health/Medical History