Fillable New Patient Form (Page 9 of 16) in pdf

New Patient Form Page 9

Download a blank fillable New Patient Form in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete New Patient Form with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

Harmony Family Dental

10103 N. DIVISION SUITE 201

SPOKANE, WA 99218

509-467-1562

Have you ever had:

Check all that apply.

Arthritis

Seizures

Abnormal bleeding

Recent weight loss

Arteriosclerosis

Fainting

Ulcers/colitis

Rheumatism

Birth defects

Hearing disorders

Difficulty breathing

Scarlet fever

Cancer

High or low blood

Hospitalized for any

Sexually transmitted

sugar

reason

disease

Emotional problems

Hypotension (low

Emphysema

Sickle cell anemia

Head or face injury

blood pressure)

Glaucoma

Sinus trouble

Heart murmur/trouble

Nervous disorder

Thyroid disease

Tattoos/body piercing

History of substance

Rheumatic fever

abuse/drug addiction

Angina

TMD/TMJ (jaw pain)

Heart attack/stroke

Kidney problems

Artificial hip/joints

X-ray or cobalt

Heart surgery

treatment

Numbness of arms or

Gout

hands

Pacemaker

Yellow jaundice

Chest pain

Swollen, still painful

Artificial valves

Chronic fatigue

Circulatory problems

joints

syndrome

Congenital heart

Cold sores

Allergies

defect

Cough-persistent or

Congenital heart

bloody

Asthma

Mitral valve prolapse

lesion

Latex sensitivity

Blood disease

Artificial bones/joints

Cortisone medicine

Smoker

Diabetes

Shingles

Convulsions

Swelling of feet/ankles

Endocrine problems

HIV/AIDS

Herpes

Swollen neck glands

Intestinal disorders

Blood transfusions

Leukemia

Tonsillitis

Hepatitis A, B, or C

Fever blisters

Excessive thirst

Tumor or growth on

Hypertension (high

Sinus problems

Hay fever

head/neck

blood pressure)

Severe/frequent

Heart disease

Easily winded

Liver problems

headaches

Hives/skin rash

Anaphylaxis

Pneumonia

Cancer/chemotherapy

Hypoglycemia

Alzheimer's disease

Shortness of breath

Radiation treatments

Irregular heartbeat

Frequent diarrhea

Anemia

Psychiatric problems

Lung disease

Genital herpes

Bruise easily

Tuberculosis

Osteoporosis

Renal dialysis

Dizziness

Venereal disease

Pain in jaw joints

Spina bifida

Epilepsy

Hemophilia

Parathyroid disease

Have you ever had an adverse reaction or allergies to any medication or substance?

Check all that apply.

Acrylic

Dental anesthetics

Nitrous oxide

Tetracycline

Aspirin

Erythromycin

Novocaine

Valium

Barbiturates (sleeping

Iodine

Penicillin/antibiotics

Xylocaine

pills)

Latex rubber

Sedatives

Codeine

Metals

Sulfa drugs

Page 9/16

New Patient Form Page 9

Related Articles

Related forms

Related Categories