New Patient History

Medical History

Patient Name:

Sex:

Date:

Date of Birth:

Social Security #:

Nickname:

Street Address:

City:

State:

Zip Code:

Driver's License #:

(Email):

Phone (Home):

Cell:

Work:

General Health:

Excellent Good Fair

Date of last physical exam:

Physician's Name:

Phone Number:

Are you under current medical treatment?

Yes No

If yes, please explain:

Are you currently taking any medication?

Yes No

If yes, please list:

Do you have any allergies or adverse reaction to drugs?

Yes No

If yes, please list:

Have you ever been told you need to take antibiotics for dental treatments?

Yes No

Have you had excessive weight loss or gain in the last year?

Yes No

Do you use any form of tobacco?

Yes No

Have you traveled out of the country or been exposed to Tuberculosis?

Yes No

Has a Physician ever informed you that you have or have had any of the following?

Rheumatic Fever

Yes No

Respiratory Disease/Problem

Yes No

Intestinal/Stomach Disease

Yes No

Heart Murmur

Yes No

Mitral Valve Prolapse

Yes No

Cancer

Yes No

Other Heart Ailment

Yes No

Chemo/Radiation Therapy

Yes No

Artificial Joints

Yes No

Liver Disease/Hepatitis

Yes No

HIV or AIDS

Yes No

Kidney Disease

Yes No

Tuberculosis

Yes No

Major Operation

Yes No

Pacemaker

Yes No

Diabetes

Yes No

High/Low Blood Pressure

Yes No

Stroke

Yes No

Fainting Spells

Yes No

Psychological Treatment

Yes No

Epilepsy/Seizures

Yes No

Alzheimer's

Yes No

Head Injuries

Yes No

Glaucoma

Yes No

Blood Disorder

Yes No

Caffeine Dependency

Yes No

Latex Sensitivity

Yes No

Drug/Alcohol Dependency

Yes No

Sinus Problems

Yes No

Organ Transplant

Yes No

Arthritis/Osteoarthritis

Yes No

Osteoporosis

Yes No

Women Only: Are you:

Pregnant Nursing on Hormone Therapy on Birth Control Medication

Review By:

Date:

Needs Premed?

Yes No

Updates:

By:

Date:

Add New Update

Dental History

When was your last cleaning and examination?

Your last dental x-ray?

Who was your previous dentist?

Phone:

What influenced you to change dentists?

What is your immediate dental concern?

What are your Dental Goals?

How often do you brush?

How often do you floss?

Do you use any other dental aids?

If you wear a removable partial or complete denture, please complete the following:

How long have you worn your present denture/partial?

When did you receive your first partial or complete denture?

Is your present denture a problem?

Yes No

Describe:

Are you satisfied with the appearance?

Yes No

Describe:

Are you satisfied with the comfort?

Yes No

Describe:

Are you satisfied with your chewing ability?

Yes No

Describe:

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