McCallum Dental New Patient Registration

McCallum Dental New Patient Registration

Health History Form
Name*

First NameLast Name
Email*
example@example.com
Date of Birth*

MonthDayYear
Date
Gender*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Emergency Contact Info
Name

First NameLast Name
Phone Number
Relationship to Patient
Medical Information
Last Dentist (name and number)
Current Physician (name and number)
Medical History
Do you have any of the following diseases or problems?*

Active COVID 19?Fever, cough and/or sneez?Been exposed to anyone with COVID-19?None
Are you under the care of a physician?

YesNo
If yes, include name, address, phone number and reason.
Are you in good health?

YesNo
Have there been any changes in your health in the past year?

YesNo
If yes, please explain.
Date of last physical exam?
Have you been hospitalized in the past 5 years?

YesNo
If yes, list reason and date.
Please list all prescription and over the counter medications including name, dosage, purpose and time of day taken.
Do you use controlled substances (drugs)?

YesNo
If yes, which ones?
Do you use tobacco?

YesNo
If yes, what kind, how often.
Do you drink alcohol?

YesNo
If yes, how many drinks in last 24 hours? How many per week?
Have you had an orthopedic total joint (hip, knee, elbow, finger, etc) replacement?

YesNo
If yes, include date, type of replacement and any complications.
Provide orthopedic surgeons name and number.
Are you?

Taking birth control or hormone replacementNursingPregnant or trying to get pregnant
Are you allergic to or had a reaction to the following?*

Local anestheticsBarbituratesCodeine or other narcoticsLatexHay feverFoodPenicillin or other antibioticsSulfa drugsMetalsIodineAnimalsSedativesJeweleryNo AllergiesOther
If yes to any please specify type and reaction.
Please indicate if you have or have had any of the following diseases or problems.

Cardiovascular diseaseCongestive heart failureLow blood pressureMitral valve prolapseRheumatic heart diseaseBlood transfusionArthritisSystemic lupus erythematousEmphysemaChest pain upon exertionEating disorderGI reflux/ persistent heart burnAnginaHeart attackHigh blood pressurePacemakerAbnormal bleedingHemophiliaAutoimmune diseaseAsthmaSinus troubleChronic painMalnutritionUlcersArteriosclerosisHeart murmurOther congenital heart defectRheumatic feverAnemiaAIDS/HIVRheumatoid arthritisBronchitisCancer/chemotherapy/radiationDiabetes 1 or 2Gastrointestinal diseaseThyroid problemStrokeEpilepsySleep disorderRecurrent infectionOsteoporosisSevere or rapid weight lossGlaucomaFainting spells or seizuresSnoringKidney problems/dialysisPersistent swollen glands in neckSexually transmitted diseaseDamaged heart valvesHepatitis, jaundice or ulcersNeurological disorderMental health disorderNight sweatsSevere headaches/ migrainesExcessive urinationHerpes, cold sores, fever blistersOther
If yes to any, list dates, kinds, controlled or uncontrolled
If yes to any of the following CHD conditions, antibioticprophylaxis is recommended. Consult physician.

Artificial (prosthetic) valvePrevious infective endocarditisDamaged valves in transplanted heartCHD; unrepaired cyanotic CHDCHD; repaired completely in last 6 monthsCHD; repaired with residual defects
Has a physician or specialist recommended that you take antibiotics prior to dental treatment?

YesNo
Do you have any diseases or problems not listed above that you think I should know about?*

YesNo
If yes, what?
Grind your teeth?

PresentPastNever
Bite your cheek?

PresentPastNever
Mouth breather?

PresentPastNever
How often do you brush? When?
How often do you floss? When?
Do you use mouthwash? What type?
Other types of oral health instruments?
Personal or family history of oral cancers?

YesNoHigh risk
Are you currently experiencing pain in your mouth?

YesNo
If yes, where at, what type and for how long?
Are your teeth sensitive to hot/cold

PresentPastNever
Are your teeth sensitive to biting or chewing?

PresentPastNever
Are your teeth sensitive to sweets?

PresentPastNever
If present or past to any, please explain.
Have you had a serious injury to your mouth or head?

PresentPastNever
If present or past to any, please list what, dates, and reasons.
Any complications from dental treatment?
Primary Insurance
Dental Coverage

YesNo
Dental Insurance Company and Number
Payment Policy

Payment is due upon completion of treatment. Please note that all services may not be covered by insurance coverage. It is patient's responsibility to cover the procedures that are not covered by their insurance plan.
I, first and last name , shall inform the dentist and staff at the next appointment without fail, if I have any changes in my health status or if my medications change. To the best of my knowledge, all the preceding answers are correct.
Signature*

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McCallum Dental New Patient Registration

Emergency Contact Info

Medical Information

Medical History

Payment Policy