New Patient Form

FInch Family Dentistry

Medical History Questionnaire
Contact Information
Salutation:*

Mr.Mrs.Ms.MissDr.Other
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Gender*

FemaleMaleOther
Which one do you prefer to be contacted?

EmailPhoneOther
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Reason for the today's Appointment?*
When was your last visit to Dentist

MonthDayYear
Date
When was your last Dental X-Ray?

MonthDayYear
Date
What kind of dental work you had in past?
Are you tense/anxiety issue during dental visits?*

YesNo
Insurance details (Primary):

Company

Name of Policy Holder

Group Policy/Plan NumberID/Certificate Number

D.O.B. of Policy Holder
Insurance details (Secondary):

Company

Name of Policy Holder

Group Policy/Plan NumberID/Certificate

D.O.B. of Policy Holder
Emergency Contact
Name*

First NameLast Name
Relationship
Phone Number*
Please enter a valid phone number.
Health Information
Do you have any allergies?*

YesNo
Please give details (Please type N/A if No)*
Other Health Care Providers (If Applicable)
Check all the medical conditions that apply to you:*

Abnormal BleedingAIDS/HIVAllergiesAnemiaAnginaArteriosclerosisArthritisArtificial Heart ValveArtificial JointsAsthmaAutoimmune DiseaseBlood Disease/HemophiliaBlood ThinnerBlood TransfusionCancerChest Pain Upon ExertionChronic PainCodeine AllergyCongenital Heart DiseaseCongestive Heart FailureCoumadinDamaged Heart ValveDiabetesDizzinessEating DisorderEmphysemaEpilepsyExcessive BleedingExcessive UrinationFainting SpellsG.E Reflux/Persistent HeartburnGlaucomaGrowthsHay FeverHead InjuriesHearing ImpairedHeart AttackHeart DiseaseHeart MurmurHepatitisHigh Blood PressureJaundiceKidney ProblemsLiver DiseaseLow Blood PressureMalnutritionMental DisordersMitral Value ProlapsNervous DisordersNight SweatsOsteoporosisPacemakerPersistent Swollen Neck GlandsPrevious Infective EndocarditisRadiation TreatmentRecurrent InfectionsRespiratory ProblemsRheumatic FeverRheumatic Heart DiseaseSeizuresSevere Headaches/MigrainesSevere or Rapid Weight LossSinus ProblemsSleep DisorderSpina BifidaStomach ProblemsStrokeSystemic Lupus ErythematosusThyroid ProblemsTuberculosisTumorsUlcersVenereal DiseaseNoneOther
Do you have any of the following allergies?*

AspirinBarbiturateCleocinClindamycinEpinephrineErythromycinFoodIodineLatexLocal AnestheticsMetalsPenicillinSedativeSulfaTetracyclineNoneOther
Surgeries/ Hospitalizations/ Injuries
Current & Recent Medications
For Woman only: (Check all that apply)

PregnantBirth Control PillsHormone ReplacementNursing
I certify that I have read and understood the above and that the information given on this form is accurate. I understand the importance of a truthful dental history, and that my dentist and his/her staff will rely on this information when treating me. I acknowledge that my questions, if any, about inquires set forth above have been answered to my satisfaction. I will not hold my dentist, or any other member of his/her staff, responsible for any action they take or do not take because of my errors or omissions that I may have made in the completion of this form.
Date*

MonthDayYear
Date
Signature*

Clear
Should be Empty:

FInch Family Dentistry

Contact Information

Emergency Contact

Health Information