New Patient Medical / Dental History
Medical History
(This information will be held in strict confidence)
Date
*
-
Month
-
Day
Year
Name
*
First Name
Last Name
Preferred Name
Date of Birth
*
January
February
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April
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June
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October
November
December
Month
1
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31
Day
2023
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2020
2019
2018
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2012
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1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Gender
*
Please Select
Male
Female
Marital Status
Please Select
Single
Married
Widowed
Divorced
Separated
Spouse’s Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone Number
Please enter a valid phone number.
Work Phone Number
Please enter a valid phone number.
Cell Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Emergency Contact
Emergency Contact Name
*
Emergency Contact Phone Number
*
Please enter a valid phone number.
Referred By
Dental Questionnaire
Date of most recent dental visit
-
Month
-
Day
Year
Date
Does dental treatment make you nervous?
*
No
Somewhat
Extremely
My mouth is
*
Very comfortable
Moderately Comfortable
Uncomfortable
I think the appearance of my mouth is
*
Excellent
Satisfactory
Unsatisfactory
Do you use the following?
*
Toothbrush
Dental Floss
Oral Irrigator
Other
If "Other" Please Explain
*
How often do you brush?
Do you use a soft toothbrush?
*
Yes
No
Have you ever been treated for periodontal disease (gum disease)?
*
Yes
No
Do you have, or have you ever experienced the following?
Bleeding, Sore Gums
*
Yes
No
Unpleasant Taste / Bad Breath
*
Yes
No
Burning Tongue / Lips
*
Yes
No
Frequent Mouth Blisters
*
Yes
No
Swelling / Lumps in Mouth
*
Yes
No
Orthodontic Treatment (Braces)
*
Yes
No
Biting Cheeks / Lips
*
Yes
No
Clicking / Popping Jaw
*
Yes
No
Loose Teeth
*
Yes
No
Sensitive to Hot
*
Yes
No
Sensitive to Cold
*
Yes
No
Biting Sensitivity
*
Yes
No
Food Impaction
*
Yes
No
Shifting in Bite
*
Yes
No
Clenching / Grinding
*
Yes
No
When?
*
Are you having any discomfort at this time?
*
Yes
No
If "Yes" Please Explain
*
These are the things that are important to me regarding my dental health
*
Yes
No
Health Questionnaire
Are you in good health?
*
Yes
No
If Not, Explain Briefly
*
Are you under a physician’s care now?
*
Yes
No
If "Yes" Please Explain
*
Name of health care practitioner
Date of last Physical
-
Month
-
Day
Year
Date
Have you had any serious illness or operations?
*
Yes
No
If "Yes" Please Explain
*
Are you taking any medications? Including OTC supplements
*
Yes
No
If yes, Please List
*
Are you allergic OR have you reacted adversely to
Aspirin
Sulfa drugs
Latex
Penicillin or other antibiotics
Lodine
Local Anesthetics
Codeine or other analgesic
Allergies to other meds
If "Allergies to other meds" Please Explain
*
Do you have, or have you had, any of the following?
Anemia
*
Yes
No
Arthritis
*
Yes
No
Asthma
*
Yes
No
Blood Transfusion
*
Yes
No
Breathing Problems
*
Yes
No
Bruise Easily
*
Yes
No
Cancer
*
Yes
No
Type
*
Chemotherapy
*
Yes
No
Chronic Fatigue Syndrome
*
Yes
No
Cold Sores / Fever Blisters
*
Yes
No
Diabetes
*
Yes
No
Do you take Insulin?
*
Yes
No
Drug Addiction
*
Yes
No
Emphysema
*
Yes
No
Environmental Sensitivities
*
Yes
No
Epilepsy or Seizures
*
Yes
No
Epstein Barr Virus
*
Yes
No
Excessive Bleeding
*
Yes
No
Fibromyalgia
*
Yes
No
Frequent Headaches
*
Yes
No
Hearing / Vision Loss
*
Yes
No
Hemophilia
*
Yes
No
Hepatitis
*
Yes
No
Type
*
A
B
C
Herpes
*
Yes
No
High Cholesterol
*
Yes
No
Hives / Skin Rash
*
Yes
No
Joint Pain / Inflammatory Rheumatism
*
Yes
No
Joint Replacement
*
Yes
No
If "Yes" Please Explain
*
Kidney Problems
*
Yes
No
Lung Disease
*
Yes
No
Multiple Chemical Sensitivity
*
Yes
No
Psychiatric Care
*
Yes
No
Radiation
*
Yes
No
Sexually Transmitted Disease
*
Yes
No
Stroke
*
Yes
No
Thyroid Disease
*
Yes
No
Tobacco
*
Yes
No
Type
*
How Often?
*
Tuberculosis
*
Yes
No
Ulcers
*
Yes
No
Vertigo
*
Yes
No
HEART
Congenital Heart Lesions
Yes
No
Rheumatic Fever
Yes
No
High Blood Pressure
Yes
No
Low Blood Pressure
Yes
No
Irregular Heart Beat
Yes
No
Cardiovascular Disease
Yes
No
Heart Murmur
Yes
No
Mitral Valve Prolapse
Yes
No
Do you have a pacemaker?
Yes
No
Are you on blood thinners?
Yes
No
WOMEN
Pregnant
Yes
No
Nursing
Yes
No
Taking oral contraceptive
Yes
No
Signature of Patient, Parent or Guardian
Clear
Name of Patient, Parent or Guardian
First Name
Last Name
Date
-
Month
-
Day
Year
Date
Submit
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