New Patient Medical History Form

PrefixFirst NameMiddle NameLast Name

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Please enter a valid phone number.

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Please enter a valid phone number.

SelfSpouseChildOther

Please enter a valid phone number.

The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to the physician. I understand that I am financially responsible for any balance. I also authorize Dr. Singh to release any information required to process my claims.

Please enter a valid phone number.

Please list all medications (prescription and over the counter), vitamins and diet/herbal supplements you are taking. You may also provide a copy of medications.

	Drug	Dose/Frequency	Reason
Medication:
Medication:
Medication:
Medication:
Medication:
Medication:

Please answer Yes or No to if you have had the following conditions.

	Yes	No
Cardiovascular disease
Angina
Arteriosclerosis
Congestive Heart Failure
Damaged heart valves
Heart attack
Heart murmur
Low blood pressure
High blood pressure
Other congenital heart defects
Artificial (prosthetic) heart valve
Previous infective endocarditis
Damaged valves in transplanted heart
Congenital heart disease (CHD); Unrepaired, cyanotic CHD; Repaired (completely) last 6 Mo; Repaired CHD with residual defects
Mitral valve prolapses
Pacemaker
Rheumatic fever
Rheumatic heart disease
Abnormal bleeding
Anemia
Blood transfusion
Hemophilia

	Yes	No
AIDS/HIV infection
Arthritis
Autoimmune disease
Rheumatoid arthritis
Lupus
Asthma
Bronchitis
Emphysema
Sinus trouble
Tuberculosis
Cancer
Chemotherapy or radiation treatment
Chest pain upon exertion
Chronic pain
Diabetes type I or II
Eating disorder
Malnutrition
Gastrointestinal disease
G.E. reflux/heartburn
Ulcer
Thyroid disease
Glaucoma

	Yes	No
Hepatitis, jaundice or liver disease
Epilepsy
Seizures
Neurological disorders
Sleep disorder
Mental health disorder
Recurrent infections
Kidney problems
Night sweats
Osteoporosis
Persistent swollen glands in neck
Severe headaches/migraines
Severe or rapid weight loss
Excessive urination
Sexually transmitted disease

JOINT REPLACEMENT:

I certify that I have read and understand the above and that the information given on this form is accurate. I understand the importance of a truthful health history and that my dentist and his/her staff will rely on this information for treating me. I acknowledge that my questions, if any, about inquiries 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 errors or omissions that I may have made in the completion of this form.

	Yes	No
Do your gums bleed when you brush or floss?
Are your teeth sensitive to cold, hot, sweets or pressure?
Does food or floss catch between your teeth?
Is your mouth dry?
Have you had any problems associated with previous dental treatment?
Is your home water supply fluoridated?
Do you drink bottled or filtered water?
Have you ever had orthodontic (braces) treatment?
Do you have earaches or neck pains?
Do you have any clicking, popping or discomfort in the jaw?
Do you brux or grind your teeth?
Do you have sores or ulcers in your mouth?
Do you wear dentures or partials?
Have you ever had a serious injury to your head or mouth?

New Patient Medical History Form

NEW PATIENT INFORMATION

INSURANCE/FINANCIAL INFORMATION

IN CASE OF EMERGENCY

MEDICAL HISTORY

Dental History