New Patient Form - Maple DA

Maple Dental Associates, PC.

Patient Registration & Medical History Form
Patient Name:
Gender:
Date of Birth:

MonthDayYear
Date
Guardian Name if under 18:
Relationship to patient & phone #:
Emergency Contact if over 18:
Relationship to You & Phone #:
Home Phone:
Work Phone:
Cell Phone:
Mailing Address:

Mailing Address

Street Address Line 2

City State ZipState / Province

Postal / Zip Code
E-Mail Address:
example@example.com
Preferred Contact Method:
Preferred Pharmacy Name:
Pharmacy Phone Number:
MEDICAL HISTORY & MEDICATIONS
Are you now under the care of a physician?
Physician's Name:
Please explain:
Do you take any blood thinner medications?

YesNo
If yes type:
Are you presently taking, or have you ever taken any of the following bisphosphonate medications?

Etidronate (Didronel)Nisedronate (Actonel) Zoledronate(Zometa) Pmidronate (Aredia)Ibandronate (Boniva)Tiludronate (Skelid) Zoledronic Acid(Reclast) Alendronate (Fosomax)RANK Ligand Inhibitos:Denosumab (Xgeva, Prolia)
List any other prescription and/or over-the-counter drugs you are taking:
Women Only
Are you taking Birth Control Pills?

YesNo
Are you pregnant?

YesNo
#Weeks
Are you Nursing?

YesNo
Are you allergic to any of the following? (Please Check All That Apply)

AspirinCodeineDental AnestheticsErythromycinLatexPenicillinTetracyclineJewelry MetalsSeaweedSulfa
Other Allergies Please List:
Do you use tobacco?

YesNo
If YES, frequency
Are you allergic to any of the following? (Please Check All That Apply)

AnemiaChemotherapyFever Blisters/HerpesHIV/AIDS/HepatitisArthritisHigh/Low BloodShinglesAnxiety with Dental VisitsCobaltGlaucomaStrokeRheumatic FeverDepressionSinus ProblemsThyroid ProblemsKidney ProblemsLiver ProblemsSleep ApneaDiabetesHeart MurmurUlcersHeart AttackArtificial JointsLupusTuberculosisPsychiatric IssuesArtificial ValvesOpthalmic Eye SurgeryCold SoresCongenital Heart DefectMitral Valve ProlapseAsthma/Difficulty BreathingBack ProblemsDrug/Alcohol AbuseHemophilia/Abnormal BleedingCancer/RadiationTxEpilepsy/ConvulsionsPressure Severe Headaches
Do you have any artificial joints and/or a medical condition that would require antibiotic Pre-Medication?

YesNo
Please Specify:
Date of Joint Replacement (approx):

MonthDayYear
Date
Surgeon's Name
Name of Previous Dentist:
Date of Last Visit:

MonthDayYear
Date
What was done at that time?
Why have you come to the dentist today?
Are you currently experiencing dental pain or discomfort?

YesNo
If YES, please explain:
How many times per day do you brush?
Floss?
Do you use a hard, medium, or soft brush?
For the following questions please check. Y = YES; N = NO; or S = SOMETIMES
Do your gums bleed when you brush or floss?

YesNoSometimes
Do you have earaches or neck pains?

YesNoSometimes
Are your teeth sensitive to cold, hot, sweets, or pressure?

YesNoSometimes
Do you have any jaw clicking, popping, or discomfort?

YesNoSometimes
Is your mouth dry?

YesNoSometimes
Do you brux or grind your teeth?

YesNoSometimes
Have you had any periodontal (gum) treatments?

YesNoSometimes
Do you have sores or ulcers in your mouth?

YesNoSometimes
Have you ever had orthodontic treatment?

YesNo
Do you wear dentures or partials?

YesNoSometimes
Have you had any problems with previous dental treatment?

YesNo
Have you ever had a serious head or mouth injury?

YesNoSometimes
Is your home water supply fluoridated?

YesNo
Do you like your smile?

YesNoSometimes
Primary Dental Insurance:
Policy Holder Name:
Employer:
Subscriber ID:
Social Security#:
Date of Birth:

MonthDayYear
Date
Primary Dental Insurance Company:
Group#:
Secondary Dental Insurance:
Policy Holder Name:
Employer:
Subscriber ID:
Social Security#:
Date of Birth:

MonthDayYear
Date
Secondary Dental Insurance Company:
Group #:
AUTHORIZATION FOR TREATMENT: I understand that the information that I have given today is correct to the best of my knowledge. I alsounderstand that this information will be held in the strictest confidence and that it is my responsibility to inform this office of any change in mymedical status. I authorize the dental staff to perform any necessary dental services that I may need during diagnosis and treatment with myinformed consent.
Signature

Clear
Date

MonthDayYear
Date
Doctor Signature

Clear
Date

MonthDayYear
Date
Maple Dental Associates, PC. complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex.
Should be Empty:

Maple Dental Associates, PC.

MEDICAL HISTORY & MEDICATIONS

Women Only

For the following questions please check. Y = YES; N = NO; or S = SOMETIMES

Primary Dental Insurance:

Secondary Dental Insurance: