New Patient Form

* MEDICAL HISTORY

1. Are you under medical treatment now?

Yes No

2. Have you ever been hospitalized for any surgical operation or serious illness?

Yes No

3. Are you taking any medication(s) including non-prescription medicine?

Yes No

4. Have you ever taken Fen-Phen/Redux?

Yes No

5. Do you use tobacco?

Yes No

6. Do you use alcohol, cocaine or other drugs?

Yes No

7. Are you wearing contact lenses?

Yes No

8. Are you allergic to or have had any reactions to the following?

8.1) Local anesthetics (Eg.Novocaine)

Yes No

8.2) Penicillin or other antibiotics

Yes No

8.3) Sulfa Drugs

Yes No

8.4) Barbiturates

Yes No

8.5) Sedatives

Yes No

8.6) lodine

Yes No

8.7) Latex

Yes No

8.8) Aspirin

Yes No

8.9) Codeine

Yes No

9. Women only:

a) Are you pregnant or think you may be pregnant?

Yes No

b) Are you nursing?

Yes No

C) Are you taking birth control pills?

Yes No

10. Do you have a persistent cough or throat clearing not associated with a known illness (lasting more than 3 weeks)?

Yes No

11. Have you been treated with any of the following disease (s) or symptom (s)

11.1) High Blood Pressure

Yes No

11.2) Heart Attack

Yes No

11.3) Rheumatic Fever

Yes No

11.4) Swollen Ankles

Yes No

11.5) Fainting/Seizures

Yes No

11.6) Low Blood Pressure

Yes No

11.7) Epilepsy| Convulsions

Yes No

11.8) Leukemia

Yes No

11.9) Diabetes

Yes No

11.10) Kidney Diseases

Yes No

11.11) AIDS or HIV Infection

Yes No

11.12) Thyroid Problem

Yes No

11.13) Heart Disease

Yes No

11.14) Cardiac Pacemaker

Yes No

11.15) Heart Murmur

Yes No

11.16) Angina

Yes No

11.17) Frequently Tired

Yes No

11.18) Anemia

Yes No

11.19) Emphysema

Yes No

11.20) Cancer

Yes No

11.21) Arthritis

Yes No

11.22) Joint Replacement or Implant

Yes No

11.23) Hepatitis | Jaundice

Yes No

11.24) Sexually Transmitted Disease

Yes No

11.25) Stomach Troubles | Ulcers

Yes No

11.26) Chest Pain

Yes No

11.27) Easily Winded

Yes No

11.28) Stroke

Yes No

11.29) Hay Fever | Allergies

Yes No

11.30) Tuberculosis

Yes No

11.31) Radiation Therapy

Yes No

11.32) Glaucoma

Yes No

11.33) Recent Weight Loss

Yes No

11.34) Liver Disease

Yes No

11.35) Mitral Vavle Prolapse

Yes No

11.36) Respiratory Problems

Yes No

* Patients Dental History

1. Do your gums bleed while brushing or flossing?

Yes No

2. Are your teeth sensitive to hot or cold liquids/foods?

Yes No

3. Are your teeth sensitive to sweet or sour liquids/foods?

Yes No

4. Do you feel pain to any of your teeth

Yes No

5. Do you have any sores or lumps in or near mouth?

Yes No

6. Have you had any head, neck or jaw injuries?

Yes No

7. Have you ever experienced any of the following problems in your jaw?

7.1) Clicking

Yes No

7.2) Pain (joint, ear, side of face)

Yes No

7.3) Difficulty in opening or closing

Yes No

7.4) Difficulty in chewing

Yes No

8. Do you have frequent headaches?

Yes No

9. Do you clench or grind your teeth?

Yes No

10. Do you bite your lips or cheeks frequently?

Yes No

11. Have you ever had any difficult extractions in the past?

Yes No

12. Have you ever had any orthodontic treatment?

Yes No

13. Have you ever had prolonged bleeding following extractions?

Yes No

14. Have you ever had instruction on the correct method of brushing of your teeth?

Yes No

15. Do you have a bad breath?

Yes No

16. Have you had any periodontal treatment?

Yes No

17. Does Food collect between your teeth?

Yes No

18. Have you ever had a negative dental experience?

Yes No

* Required Fields