www.safedentalsmiles.com - New Patient Medical History

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 NameMiddle NameLast Name
Medical History

Indicate which of the following you have had or have at present.
AllergiesAllergy - AspirinAllergy - CodeineAllergy - ErythroAllergy - Hay FeverAllergy - LatexAllergy - OtherAllergy - PenicillinAllergy - SulfaAnemiaArthritisArtificial JointsAsthmaBlood DiseaseCancerDiabetesDizzinessEpilepsyExcessive BleedingFaintingGlaucomaHead InjuriesHeart DiseaseHeart MurmurHepatitisHigh Blood Pressure
HIVJaundiceKidney DiseaseLiver DiseaseLow Blood PressureMental DisordersMVPNervous DisordersOtherPacemakerPre-Med - AmoxPre-Med - ClindPre-Med - OtherRadiation TreatmentRespiratory ProblemsRheumatic FeverRheumatismSinus ProblemsStomach ProblemsStrokeThyroid ProblemTuberculosisTumorsUlcersVenereal Disease
A smoker or smoked previouslyEver been hospitalized (illness or injury)FEMALE: PregnantFEMALE: Taking birth control pill
Presently being treated for any other illnessesTaking dietary supplementsTaking 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?*

YesNo
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?*

YesNo
List all medications*
Have you taken supplements, and/or vitamins within the last two years?*

YesNo
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 jointYou have problems chewingYour teeth changed in the last 5 years, become shorter, thinner, or wornYour teeth are crowding or developing spacesYou chew ice, bite your nails, use your teeth to hold objects, or have any other oral habitsYou clench your teeth in the daytime or make them soreYou have problems with sleep or wake up with an awareness of your teethYou wear or have worn a bite appliance
Tooth structure, Check all the apply

Cavities within the past 3 yearsThe amount of saliva in your mouth seems too little or you have difficulty swallowing any foodYou notice or have holes (i.e. pitting, crates) on the biting surface of your teethAny teeth sensitive to hot, cold, biting, sweets, or avoid brushing any part of your mouthGrooves or notches on your teeth, chipped teeth, or had a toothache or cracked fillingFood gets caught between any teeth
Gum and Bone, Check all the apply

Gums bleed when brushing or flossingTreated for gum disease or were told you have lost bone around your teethNoticed an unpleasant taste or odor in your mouthHistory or periodontal disease in your familyExperienced gum recessionHad any teeth become loose on their own (without injury), or have difficulty eating an appleExperienced a burning sensation in your mouth
If any of the checked boxes need further explanation, please describe
Signature*
Patient Name*

First NameLast Name
Date*

MonthDayYear
Date
Should be Empty:

Please Fill Out The Forms Only When The Appointment Is Scheduled.

New Patient Medical History

Medical History