New Patient

First Name

Last Name

Preferred Name

Email Address

Phone Number

Age

Referred by

How would you rate the condition of your mouth?

Previous Dentist

How long have you been a patient

Date of most recent dental exam

Date of most recent x-rays

Date of most recent treatment (other than a cleaning)

I routinely see my dentist every

What is your immediate concern?

Please ensure all required (*) input are filled correctly

1. Are you fearful of dental treatment?

Yes No

2. Have you had an unfavorable dental experience?

Yes No

3. Have you ever had complications from past dental treatment?

Yes No

4. Have you ever had trouble getting numb or had any reactions to local anesthetic?

Yes No

5. Did you ever have braces, orthodontic treatment or had your bite adjusted?

Yes No

6. Have you had any teeth removed or missing teeth that never developed?

Yes No

Please ensure all required (*) input are filled correctly

Name of Physician and their specialty

Most recent physical examination

Purpose

What is your estimate of your general health?

Do you have or have you ever had:

1. Hospitalization for illness or injury

Yes No

3. Heart problems, or cardiac stent within the last six months

Yes No

4. History of ineffective endocarditis

Yes No

5. Artificial heart valve, repaired heart defect (PFO)

Yes No

6. Pacemaker or implantable defibrillator

Yes No

7. Orthopedic implant (joint replacement)

Yes No

8. Rheumatic or scarlet fever

Yes No

9. High or low blood pressure

High Normal Low

10. A stroke (taking blood thinners)

Yes No

11. Anemia or other blood disorder

Yes No

12. Prolonged bleeding due to a slight cut (INR > 3.5)

Yes No

13. Emphysema, shortness of breath, sarcoidosis

Yes No

14. Tuberculosis, measles, chicken pox

Yes No

15. Asthma

Yes No

Please ensure all required (*) input are filled correctly

Do you have or have you ever had:

16. Breathing or sleep problems (i.e. sleep apnea, snoring, sinus)

Yes No

17. Kidney disease

Yes No

18. Liver disease

Yes No

19. Jaundice

Yes No

20. Thyroid, parathyroid disease, or calcium deficiency

Yes No

21. Hormone deficiency

Yes No

22. High cholesterol or taking statin drugs

Yes No

23. Diabetes (HbA1c=)

Yes No

24. Stomach or duodenal ulcer

Yes No

25. Digestive disorders (i.e. celiac disease, gastric reflux)

Yes No

26. Osteoporosis/osteopenia (i.e. taking bisphosphonates)

Yes No

27. Arthritis

Yes No

28. Autoimmune disease (i.e. rheumatoid arthritis, lupus, scleroderma)

Yes No

29. Glaucoma

Yes No

30. Contact lenses

Yes No

Please ensure all required (*) input are filled correctly

Do you have or have you ever had:

31. Head or neck injuries

Yes No

32. Epilepsy, convulsions (seizures)

Yes No

33. Neurologic disorders (ADD/ADHD, prion disease)

Yes No

34. Viral infections and cold sores

Yes No

35. Any lumps or swelling in the mouth

Yes No

36. Hives, skin rash, hay fever

Yes No

37. STI / STD / HPV

Yes No

38. Hepatitis

Yes No

39. HIV / AIDS

Yes No

40. Tumor, abnormal growth

Yes No

41. Radiation therapy

Yes No

42. Chemotherapy, immunosuppressive medication

Yes No

43. Emotional difficulties

Yes No

44. Psychiatric treatment

Yes No

45. Antidepressant medication

Yes No

46. Alcohol / recreational drug use

Yes No

Are You:

47. Presently being treated for any other illness

48. Aware of a change in your health in the last 24 hours

Please ensure all required (*) input are filled correctly

List all medications, supplements, and or vitamins taken within the last two years.

Current medical treatment

Drug	Purpose

PLEASE ADVISE US IN THE FUTURE OF ANY CHANGE IN YOUR MEDICAL HISTORY OR ANY MEDICATIONS YOU MAY BE TAKING.

Please ensure all required (*) input are filled correctly

Submitted!

Do you have or have you ever had:

Do you have or have you ever had:

Do you have or have you ever had:

Are You:

List all medications, supplements, and or vitamins taken within the last two years.

PLEASE ADVISE US IN THE FUTURE OF ANY CHANGE IN YOUR MEDICAL HISTORY OR ANY MEDICATIONS YOU MAY BE TAKING.

Ready for a healthy smile?

Make your appointment today!