New Patient Enrollment Form

Name*

First NameLast Name

Date of Birth*

MonthDayYear

Gender*

Contact Number:*

Format: (000) 000-0000.

E-mail*

example@example.com

Address:*

Street Address

Street Address Line 2

CityState

Zip Code

Preferred Pharmacy*

Pharmacy NameTown

In case of emergency:

Relationship*

Emergency Contact:*

First NameLast Name

Contact Number*

Format: (000) 000-0000.

_{^{Health History:}}

Are you in good health?*

YesNo

Date of last physical exam?*

Weight (pounds)

Height (inches)

YesNo

Have you ever had any serious illnesses, operations or hospitalizations? If so, describe:*

DO YOU HAVE OR HAVE YOU EVER HAD:

Rows	Yes	No
Rheumatic Fever or Rheumatic Heart Disease
Congenital Heart Disease
Cardiovascular Disease (Heart Attack, Heart Trouble, High Blood Pressure, Stroke, Palpitations, Heart Surgery, Pacemaker)
Lung Disease (Asthma, Emphysema, COPD, Chronic Cough, Bronchitis, Pneumonia, Tuberculosis, Shortness of Breath, Chest Pain, Severe Coughing)
Seizures, Convulsions, Epilepsy, Fainting or Dizziness
Bleeding Disorder, Anemia, Bleeding Tendency, Blood Transfusion? Do you bruise easily?
Liver Disease (Jaundice, Hepatitis)
Kidney Disease
Diabetes
Thyroid Disease (Goiter)
Arthritis
Stomach Ulcers or Colitis
Glaucoma
Osteoporosis
Sleep Apnea or use of CPAP machine
Implants placed anywhere in your body (Heart Valve, Pacemaker, Hip, Knee)
Radiation (x-ray) treatment for Cancer?
Clicking or popping of jaw joint, pain near ear, difficulty opening mouth, grind or clench teeth
Sinus or Nasal problems

ARE YOU TAKING ANY OF THE FOLLOWING:

Rows	Yes	No
Antibiotics
Anticoagulants (Blood Thinners)
Any disease, drug or transplant operation that has depressed your immune system?
Aspirin/Drugs such as Motrin, Aleve, Ibuprofen
High Blood Pressure medications
Steroids (Cortisone, prednisone, etc.)
Tranquilizers
Insulin or Oral Anti-Diabetic Drugs
Digitals, Inderal, Nitroglycerin or other heart drugs
Are you or have you ever medicine for osteoporosis, multiple myeloma or other cancers (Reclast, Fosamax, Actonel, Boniva, Aredia, Zometa, Prolia)
Have you ever been advised to NOT take a specific medication?

If yes, please explain:

Please list any and all medications taken, including prescription medications, diet drugs, over-the-counter medications, herbal or holistic remedies, vitamins or minerals:*

ARE YOU ALLERGIC TO /HAVE YOU HAD AN ADVERSE REACTION TO:

Rows	Yes	No
Local Anesthesia (Novocain, etc)
Penicillin or other antibiotics
Sedatives, Barbiturates
Aspirin or Ibuprofen
Codeine or other pain killers
Latex or rubber products
Metal of any kind
Chemicals or jewelry (rash or sensitivity)
Food Products

Other allergies or reactions? Please list:*

YesNo

If yes, how much per day?

YesNo

FOR WOMEN ONLY:

Rows	Yes	No
Are you pregnant or is there a chance you may be pregnant?
Are you nursing?
If you are using oral contraceptives, it is important that you understand that antibiotics (and some other medications) may interfere with the effectiveness of oral contraceptives. Therefore, you will need to use mechanical forms of birth control for one complete cycle of birth control pills, after the course of antibiotics or other medication is completed. Please consult with your physician for further guidance.

I, the above-named patient, understand the above information is necessary to provide me with dental care in a safe and efficient manner. I have answered all questions to the best of my knowledge. Dental care has my permission to ask the respective health care provider or agency, who may release such information. I will notify this dental care facility of any and all changes in my health or medications.*