New Patient Forms Page 2
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4DENTAL HISTORY
Y
N
Would you like fresher breath?
Why have you come to the dentist today?
Y
N
Would you like whiter teeth?
Y
N Ever itch?
Y
N
Do your gums ever bleed?
Y
N
Have you ever had periodontal disease?
Y
N
Are you currently in pain?
Y
N
Do you have mobility in your teeth?
Y
N
Do you require antibiotics before dental treatment?
Are your teeth sensitive to heat, cold, or anything else?
Y
N
Y
N
Have you experienced problems associated with
If yes, please indicate:
any previous dental work?
Y
N
Do you still have wisdom teeth?
Y
N
Do you now or have you ever experienced pain /
If yes, why?
discomfort in your jaw joint (TMJ / TMD)?
Previous / Present Dentist:
Good
Fair
Poor
Your current dental health is:
Last Visit Date:
Y
N
Y
N
Do you floss daily?
Brush daily?
Why did you leave your previous dentist?
Type of bristles on your toothbrush?
Hard
Med
Soft
How long do you use a toothbrush before replacing it?
What did you like most & least about any dentist you have seen?
Y
N
Do you use anything in addition to your brush and
floss?
Y
N
Are you happy with the way your smile looks?
If yes, what?
If not, what would you change?
MEDICAL HISTORY
Do you have a personal physician?
Y
N
Your current physical health is:
Good
Fair
Poor
Physician's Name:
Y
N
Do you smoke or use tobacco in any other form?
Address:
Y
N
For Women: Are you taking birth control pills?
Phone #:
Date of last visit:
Are you pregnant?
Unsure
Y
N
Y
N
Are you currently under the care of a physician?
Y
N
Are you nursing?
Week #:
Please explain:
Are you allergic to any of the following?
Y
N
Y
N
Y
N
Aspirin
Erythromycin
Sedatives
Y
N
Y
N
Y
N
Barbiturates
Jewelry / Metals
Sulfa Drugs
Y
N
Y
N
Y
N
Codeine
Latex
Tetracycline
Y
N
Y
N
Y
N
Dental Anesthetics
Penicillin
Other
Please list additional drugs/materials that causes allergic reactions:
Are you taking any of the following?
Y
N
Y
N
Y
N
Y
N
Acetaminophen
Blood Thinners
Insulin/Diabetes Drugs
Thyroid Meds
Y
N
Y
N
Y
N
Y
N
Antibiotics
Blood Pressure Meds
Nitroglycerin
Tranquilizers
Y
N
Y
N
Y
N
Y
N
Antihistamines
Cold Remedies
Recreational Drugs
Have you ever
taken Phen-Fen?
Y
N
Y
N
Y
N
Aspirin
Digitalis / Heart Meds
Steroids / Cortisone
Y
N
Are you taking any prescription, over-the-counter drugs, herbal remedies, vitamins or minerals not listed above?
if yes, please list each one:
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Parent category: Medical