New Patient Information & Medical History
Name
*
First Name
Last Name
Email
*
example@example.com
Phone (home)
*
Please enter a valid phone number.
Format: (000) 000-0000.
Phone (work)
*
Please enter a valid phone number.
Format: (000) 000-0000.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
*
-
Month
-
Day
Year
Date
Gender
*
Male
Female
Prefer not to answer
Emergency Contact (name)
*
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Physician
Physician Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Previous Dentist
Previous Dentist Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Whom can we thank for referring you to our clinic?
Medical History
When did you last see your physician, and for what reason?
*
Do you have any drug allergies that you are aware of?
*
Yes
No
Please list:
Do you have a Latex allergy?
*
Yes
No
Are you taking any Medications or Supplements?
*
Yes
No
If Yes, please list:
Did a dentist, physician, or specialist ever recommend taking antibiotics before dental treatment or surgery?
*
Yes
No
Please choose any of the following conditions that apply to you, past or present:
*
Anemia
Arthritis
Artificial Joints
Asthma
Blood Disorders
Breathing Problems
Cancer
Clotting/Bleeding Problems
Cold Sores
Depression
Diabetes
Drug Use
Epliepsy
Fainting
Gastrointestinal Disorders
Growth or Tumor
Heart Attack
Heart Disease
Heart Murmur
Hepititis A - B - C
None
(cont) Please choose any of the following conditions that apply to you, past or present:
*
HIV/AIDS
High Blood Pressure
Jaundice
Kidney Disease
Liver Problems
Low Blood Pressure
Mental/Nervous Disorders
Migraines/headaches
Osteoporosis
Pace Maker
Rheumatic Fever
Sinus Problems
Sleep Apnea
Snoring
Stroke
Surgery
Thyroid Problems
Tuberculosis
Ulcers
None
Is there anything else you would like us to know about your health?
WOMEN - Are you pregnant
Yes
No
WOMEN - Birth control pills or HRT?
Yes
No
WOMEN - Are you in peri-menopause or menopause?
Yes
No
Date
*
-
Month
-
Day
Year
Date
Signature
*
Continue
Continue
Should be Empty: