New Patient Medical Information
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Birth
*
-
Month
-
Day
Year
Date
Email
example@example.com
Do you have a Family Doctor?
*
Yes
No
If yes, please list their name, phone number, and address:
*
Are you currently under the care of any medical specialists? (e.g. Cardiologist, Neurologist, etc.)
*
Yes
No
If yes, please list their name(s), phone number(s), and address':
*
Occupation
*
Employer
*
Emergency Contact
*
Emergency Contact Number
*
How did you hear about us?
*
Google
Website
Facebook
Instagram
Existing patient
Live nearby
Other
If existing patient, please let us know who:
*
Are you being treated for any medical conditions at the present time or have you been treated within the last year?
*
Yes
No
If yes, please explain:
*
When was your last medical check up?
*
Have there been any changes in your general health in the last year?
*
Yes
No
Not sure
If yes, please explain:
*
Are you taking any medications, non-prescription drugs or herbal supplements of any kind?
*
Yes
No
If yes, please list:
*
Do you have any allergies?
*
Yes
No
Not sure
If yes, please list:
*
Have you ever had an uncommon or adverse reaction to any medicines or injections?
*
Yes
No
Not sure
If yes, please explain:
*
Do you have or have you ever had asthma?
*
Yes
No
Not sure
Do you have or have you ever had any heart or blood pressure problems?
*
Yes
No
Not sure
If yes, please explain:
*
Do you have or have ever had a replacement or repair of a heart valve, an infection of the heart, a heart condition from birth or a heart transplant?
*
Yes
No
Not sure
If yes, please explain:
*
Have you ever had hepatitis, jaundice or liver disease?
*
Yes
No
Not sure
If yes, please explain:
*
Do you have a prosthetic or an artificial joint?
*
Yes
No
If yes, please explain:
*
Do you have a bleeding problem or a bleeding disorder?
*
Yes
No
Not sure
If yes, please explain:
*
Have you ever been hospitalized for any illness or operations?
*
Yes
No
If yes, please explain:
*
Do you have any conditions that could affect your immune system? i.e. Chemotherapy, HIV, or Radiation Therapy
*
Yes
No
Not sure
If yes, please explain:
*
Do you have or have you ever had any of the following? Please check all that apply?
*
AIDS
Alzheimers
Angina
Anemia
Arthritis
Blood Transfusion
Cancer
Chest Pain
Cold Sores
Diabetes Type 1
Diabetes Type 2
Digestive Disorders/ Acid Reflux
Drug / Alcohol Dependency
Emphysema
Epilepsy or Seizures
Fibromyalgia
Head/Neck Injury
Heart Attack
Heart Murmur
High/Low Blood Pressure
HIV
Hodgkins Disease
Hypo/Hyperglycemia
Kidney Disease
Lung Disease
Lupus
Migraine
Mitral Valve Prolapse
Osteoporosis Medication
Pacemaker
Parkinsons Disease
Radiation/Chemotherapy
Rheumatic Fever
Sexually Transmitted Infection
Shortness of Breath
Steroid Therapy
Stomach Ulcers
Stroke
Thrush
Thyroid Disorder
TMJ Disorder
Tuberculosis
NONE OF THE ABOVE
Are there any conditions or disease not listed above that you have or have had?
*
Yes
No
Not sure
If yes, please explain:
*
Are there any diseases or medical problems that run in your family? (e.g. diabetes, cancer or heart disease)
*
Yes
No
Not sure
If yes, please explain:
*
Do you smoke or chew tobacco products?
*
Yes
No
If yes, how much per day and for how many years?
*
Are you nervous during dental treatment?
*
Yes
No
Not sure
If yes, please explain:
*
Are you pregnant?
*
Yes
No
Not sure
If yes, please explain:
*
When was your last dental check up?
*
Do you use electronic cigarettes or marijuana products?
*
Yes
No
If yes, please explain:
*
Is there anything about the appearance of your teeth you would like to change?
*
Yes
No
Not sure
If yes, please explain:
*
Please list anything not mentioned above regarding your past dental & medical history:
I would be interested in participating in social media and marketing (photos, x-rays, testimonials, etc.):
*
Yes
No
Not sure
The information I have given above is true to the best of my knowledge
*
Today's Date:
*
-
Month
-
Day
Year
Date
Submit
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