Click on Calendar, type the year 'YYYY' and pick the month & date.
New Patient Medical History

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


  Last name

  MidI

  First name

Medical History

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


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.)