Click on Calendar, type the year 'YYYY' and pick the month & date.
Please fill out the forms only when the appointment is scheduled.
New Patient Medical History

Please do not print the forms. Submit the forms online only.


  FIRST NAME

  Mid Initials

  LAST NAME

Medical History

* Pre-Med - Amox
Heart Murmur
* Pre-Med - Clind
Hepatitis
* Pre-Med - Other
High Blood Pressure
Allergies
HIV
Allergy - Hay Fever
Jaundice
Allergy - Latex
Kidney Disease
Allergy - Other
Liver Disease
Allergy - Penicillin
Low Blood Pressure
Allergy - Sulfa
Mental Disorders
Allergy - Aspirin
MVP
Allergy - Codeine
Nervous Disorders
Allergy - Erythro
Osteoporosis
Anemia
Pacemaker
Arthritis
Radiation Treatment
Artificial Joints
Respiratory Problems
Asthma
Rheumatic Fever
Blood Disease
Rheumatism
Cancer
Sinus Problems
Diabetes
Stomach Problems
Dizziness
Stroke
Epilepsy
Thyroid Problem
Excessive Bleeding
Tuberculosis
Fainting
Tumors
Glaucoma
Ulcers
Head Injuries
Venereal Disease
Heart Disease
* Other


A smoker or smoked previously
Ever been hospitalized (illness or injury)
FEMALE: Pregnant
FEMALE: Taking birth control pill
Presently being treated for any other illnesses
Taking dietary supplements
Taking medication for weight control (ie fen-phen)
Subject to frequent headaches

Do you take antibiotic premedication for your dental visits? Yes No
If Yes, Please Explain:

Is there anything about the appearance of your teeth that you would like to change?
Have you ever whitened (bleached) your teeth?
Have you felt uncomfortable or self-conscious about the appearance of your teeth?
Have you been disappointed with the appearance of previous dental work?

You have problems with your jaw joint
You have problems chewing
Your teeth changed in the last 5 years, become shorter, thinner, or worn
Your teeth are crowding or developing spaces
You chew ice, bite your nails, use your teeth to hold objects, or have any other oral habits
You clench your teeth in the daytime or make them sore
You have problems with sleep or wake up with an awareness of your teeth
You wear or have worn a bite appliance

Cavities within the past 3 years
The amount of saliva in your mouth seems too little or you have difficulty swallowing any food
You notice or have holes (i.e. pitting, crates) on the biting surface of your teeth
Any teeth sensitive to hot, cold, biting, sweets, or avoid brushing any part of your mouth
Grooves or notches on your teeth, chipped teeth, or had a toothache or cracked filling
Food gets caught between any teeth

Gums bleed when brushing or flossing
Treated for gum disease or were told you have lost bone around your teeth
Noticed an unpleasant taste or odor in your mouth
History or periodontal disease in your family
Experienced gum recession
Had any teeth become loose on their own (without injury), or have difficulty eating an apple
Experienced a burning sensation in your mouth


*Signature :
Date :
(Your digital signature (full name) is as legally binding as a physical signature.)
    
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