Gatlin Creek Dentistry - New Patient Dental and Medical History

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Patient Name* This field is required.
First Name
Last Name
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Email
example@example.com
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Phone Number* This field is required.
Area Code
Phone Number
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Patient's Date of Birth* This field is required.
Date
Month
Day
Year
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Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Nigeria
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Other
Country
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If you are signing this form on behalf of the patient, please type in your name.
First Name
Last Name
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Your Relationship to Patient:If you are signing this form on behalf of the patient. Example: parent, guardian
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How did you hear about us?ex. google, drive-by, referral
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Referred by:
First Name
Last Name
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Emergency Contact* This field is required.
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Date of Last Dental Visit* This field is required.
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Date of Last Complete Dental Exam* This field is required.
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Reason for Your Upcoming Visit* This field is required.
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Name of Previous Dentist
Please list dentist's name or practice name.
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Location of Previous Dentist
Please list city and state.
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Do you have teeth sensitivities?Please check all that apply.
Hot
Cold
Sweets
Pressure
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Are you nervous about dental treatment?* This field is required.
YESNO
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Do you have trouble getting numb?* This field is required.
YESNO
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Are you happy with your smile?* This field is required.
YESNO
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Are you happy with the current shade (brightness) of your teeth?* This field is required.
YESNO
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Have you ever been treated for gum disease?* This field is required.
YESNO
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Do you clench or grind your teeth?* This field is required.
YESNO
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Do you snore or does your spouse witness you snoring?* This field is required.
YESNO
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Have you ever or are you currently taking or scheduled to take any of the following medications for osteoporosis or Paget's disease?Please check all that apply.
Alendronate (Fosamax®)
Risedronate (Actonel®)
Ibandronate (Boniva®)
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Since 2001, were you treated or are you presently scheduled to begin treatment with the intravenous bisphosphonates (Aredia® or Zometa®) for bone pain, hypercalcemia or skeletal complications resulting from Paget's disease, multiple myeloma, metastatic cancer or osteoporosis? * This field is required.
YESNO
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If yes, which one?Check all that apply.
Aredia®
Zometa®
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If yes, please list date treatment began or will begin:
mm/dd/yyyy
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Are you currently under a physician's care for ongoing treatment or chronic health conditions?* This field is required.
YESNO
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If yes, what for?
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Date of Last Visit to Your Primary Health Physician
mm/dd/yyyy or mm/yyyy
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Have you been hospitalized or had a serious illness in the last 3 years?* This field is required.
YESNO
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Do you use controlled substances?* This field is required.
YESNO
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Do you have a history of Infective Endocarditis?* This field is required.
YESNO
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Do you have a history of using chewing tobacco?* This field is required.
YESNO
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Do you have or have you had...Please check all that apply.
Chest Pain
Angina
Artificial Heart Valve
Pacemaker
Shortness of Breath
Emphysema/COPD
High Blood Pressure
Asthma
Frequent Cough
Sinus Problems
Hay Fever
Dizziness
Low Blood Pressure
Fainting Spells
Frequent Headaches
Seizures
Psychiatric Care
Bleeding Problems/Bruise Easily
Hemophilia
Anemia
Blood Transfusion
Dry Mouth
Heart Murmurs
AIDS/HIV Positive
Stroke
Heart Attack
Diabetes
Cancer
Chemotherapy
Tumors or Growths
Radiation Treatment
Herpes
Ulcers
Artificial Joint
Alzheimer's Disease
Dementia
Anaphylaxis
Arthritis/Gout
Cold Sores
Convulsions
Cortisone Medicine
Drug Addiction
Stomach/Intestinal Disease
Frequent Diarrhea
Glaucoma
Hypoglycemia
Osteoporosis
Parathyroid Disease
Recent Weight Loss
Kidney Problems
Renal Dialysis
Liver Disease
Hepatitis A
Hepatitis B/C
Scarlet Fever
Shingles
Sickle Cell Disease
Tonsillitis
Thyroid Disease
Tuberculosis
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Please list any other medical conditions you have or have had, not listed above:
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Are you allergic to any of the following:
Acetaminophen
Aspirin
Codeine
Erythromycin
Ibuprofen
Latex
Metals
Penicillin
Sulfa
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Please list any other allergies you have, not listed above:
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Have you ever had a heart attack?* This field is required.
YESNO
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If yes, when?
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Are you currently pregnant?* This field is required.
YESNO
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Are you currently nursing?* This field is required.
YESNO
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Do you have an artificial heart valve?* This field is required.
YESNO
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If yes, which surgeon placed it and when?* This field is required.
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Do you have an artificial joint?* This field is required.
YESNO
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If yes, which surgeon placed it and when? Is pre-medication required?* This field is required.
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Have you ever been diagnosed with cancer?* This field is required.
YESNO
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If yes, what type of cancer? When was it diagnosed? Are you still in active treatment?* This field is required.
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Medications - please list medications you are currently taking or provide front office with list to scan:
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Signature* This field is required.Please use mouse or track pad to draw and create an e-signature.
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