Dental History

New Patient Information
Patient Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Emergency Contact Name

First NameLast Name
Emergency Contact Number
Please enter a valid phone number.Format: (000) 000-0000.
What is the main concern for which you are scheduling your appointment?
How did you hear about us?
Do you Have Dental Insurance?
Address

Street Address

Unit Number

CityState

Postal Code

Dental History

Rows	Approximates are okay
When was your last dental visit?
When did you last have dental X-rays taken?
How often do you brush your teeth?
How often do you floss?

Dental Questionnaire

Rows	Yes	No	Don't know/ N/A
Have you been seeing a dentist regularly?
Do any of your teeth ache?
Do your gums bleed when you brush?
Do you have any pain when you chew?
Do you feel that you have bad breath?
Are your teeth hot/cold sensitive?
Have you ever been in a vehicle accident or experienced any blows to your jaw?
Do you have a night guard/bite splint?
Do you drink coffee, tea or red wine?
Have you ever had any implant surgery in your jaw or any other joints?

If you answered yes to the last question, who performed the surgery and when was it done?

Are you being followed up by a dental specialist?
  Yes   No
Please list anything not mentioned above regarding your past dental history
Is there anything about your smile that you would like to change?
Medical History:
Are you currently being treated for a medical condition or have you been within the last year?
  Yes    No   Not Sure
If so, why?

When was your last medical Checkup?

Has there been any change 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?
Yes   No   Not sure
If yes, please explain

Do you have any allergies? Yes   No   Not sure
If yes, please list using the categories below:
Medications:

Latex/Rubber Products:

Other: (E.g. Hay fever, Foods)

Have you ever had an adverse reaction to any medication 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 or have you ever had any heart or blood pressure problems?
Yes   No   Not sure
Do you or have you ever had a replacement or repair of a heart valve, and infection of the heart (i.e. infective endocarditis) a heart condition from birth or a heart transplant?
Yes   No   Not sure
Have you ever had hepatitis, jaundice or liver disease? Yes   No   Not sure
Do you have a prosthetic or artificial joint? Yes   No   Not sure
Do you have a bleeding problem or bleeding disorder? Yes   No   Not sure
If yes, please explain

Have you ever been hospitalized for any illness or operations?
Yes   No   Not sure
If yes, please explain

Do you have any conditions or therapies that could affect your immune system, e.g. leukemia, AIDS, HIV infection, radiotherapy, chemotherapy?
Yes   No   Not sure

Please check any condition that you have or have had:

Rows
Alzheimers
Angina
Arthritis
Blood Transfusion
Cancer
Chest Pain
Diabetes
Drug/Alcohol Dependency
Emphysema
Epilepsy/Seizures
Fibromyalgia
Thyroid Disorder
Head/Neck Injury
Heart Attack
Heart Murmur
High/Low Blood Pressure
Hodgkins Disease
Hypo/Hyperglycemia
Kidney Disease
Lung Disease
Lupus
Migraine
Mitral Valve Prolapse
Osteoporosis Medication (e.g. fosamax, actonel)
Pacemaker
Parkinsons Disease
Radiation/Chemotherapy
Rheumatic Fever
Steroid Therapy
Stomach Ulcers
Stroke
Thrush
TMJ Disorder
Tuberculosis
Sexually transmitted Disease/Infection
Shortness of breath

Do you have any other disease/condition not listed above?
Please list any diseases or medical issues that run in your family (e.g. diabetes, cancer, heart disease)
How often do you consume alcoholic beverages?
Do you or have you ever smoked or used tobacco? Please describe type, frequency and duration
Are you currently pregnant or trying to become pregnant or breastfeeding?
Are you nervous during dental treatment
The information I have given in this form is true to the best of my knowledgeSignatureDate
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New Patient Information