Fillable New Patient Form printable pdf download

PERSONAL INFORMATION:

Patient Name:________________________________________________ Today's Date: _____________________

Home Address:________________________________________________________________________________

_________________________________________

Postal Code:_________________________________________

Male /

Female (check one)

Home Ph.#:__________________________________________

Date Of Birth: (D/M/Y)______/________/________

Cell Ph. #:___________________________________________

E-Mail:____________________________________

Work Ph. #:__________________________________________

Emergency Contact: (Name/Relationship)___________________________________________________________

Phone Number(s):______________________________________________________________________________

Internet Outside Sign Flyer Phone Book Referred by: _____________

How Did you hear about us:

Other

What is your immediate Concern today?____________________________________________________________

Any problems with Jaw

YES / NO

Are you fearful of dental treatment:

Joints?

Have you ever had trouble getting numb or reactions to Local

YES / NO

anesthetic?

MEDICAL HISTORY:

Name of Physician/and their specialty:____________________________________Phone# ___________________

Date of last medical examination:____________________________ Purpose:_____________________________

What is your estimate of your general health?:

Excellent

Good

Fair

Poor

Do you have or have you ever had any of the following: Check Yes or No

Heart Problems

YES / NO

Osteoporosis/Osteopenia

YES / NO

Heart Murmur

YES / NO

Alcohol/Drug dependancy

YES / NO

Heart Attack

Artificial Prosthesis

Rheumatic Fever

YES / NO

(heart valve or joints)

YES / NO

High Blood Pressure

YES / NO

Tuberculosis

YES / NO

Low Blood Pressure

Breathing or Sleep Problems

YES / NO

Do you take Blood Thinners?

Liver Disease

HIV/Aids

YES / NO

Arthritis

YES / NO

Tumor, Abnormal Growth

YES / NO

Head or Neck Injuries

YES / NO

Radiation Therapy

Epilepsy, Convulsions (Seizures)

Chemotherapy

YES / NO

Mental Illness

YES / NO

Venereal Disease

YES / NO

Stroke

YES / NO

Hepatitsis? Type?

Viral Infections and Cold Sores

YES / NO

Anti-Depressant Medication

Lumps or Swelling in mouth

Anemia or Blood Disorder

YES / NO

Hives, Skin Rash, Hay Fever

YES / NO

Emphysema

YES / NO

Kidney Disease

YES / NO

Asthma

Thyroid or Parathyroid Disease

Hormone Deficiency

YES / NO

Stomach or Duodenal Ulcer

YES / NO

Diabetes

YES / NO

Female: Are you taking birth control pills?

YES / NO

Digestive Disorder (Gastric Reflux)

Female: Are you pregnant?

YES / NO

Do you get frequent headaches?

Are you a smoker or previously smoked?

Are you allergic to or have you ever had an allergic reaction to any of the following? (Check all that apply)

Aspirin

Ibuprofen

Acetominophen

Codeine

Local Anesthetic

Flouride

Latex

Penicillin

Erythromycin

Tetracycline

Metals (Titanium Amalgam Stainless Steel Nickel) Any other allergies that are not listed?

_____________________________________________________________________________________________

Please list any medications, Vitamins, Herbal or Dietary Supplements currently taking and what it is for:

_____________________________________________________________________________________________

I certify that I have read and understand the above information. To the best of my knowledge, the above questions

have been accurately answered. I understand that providing incorrect information can be dangerous to my health.

Signature(Patient or

guardian):__________________________________

Date:______________________________

New Patient Form

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