Medical History New Patient
Signature will be recorded later.
Unusual reaction to dental injections?
Are you in pain?
Reason for today`s visit
Rheumatic Fever
Tobacco use? If so, what kind and how much?
City/State
Date: 4/16/2024
Date of last cleaning and exam
Do you have a Panoramic x-ray or Full Mouth x-rays that are less than 5 years old?
New patients:
Name of former dentist
Do you have BiteWing x-rays that are less than 1 year old?
Joint Replacement
Iodine
Aspirin
N
Y
Are you allergic to any of the following?
Anesthetic
N
Y
Latex
Sulfa
Ibuprofen
Penicillin
Codeine
Emergency Contact
Relationship
Phone
First Name:
Last Name:
Medical History for New Patient
City/State:
Name of Medical Doctor:
Birthdate:
List all medications that you are now taking:
Sinus Trouble
Heart Murmur
Psychiatric Treatment
Diabetes
Ulcers
High Blood Pressure
Stroke
Heart Trouble
Asthma
N
Y
Kidney Disease
N
Y
Do you have any of the following medical conditions?
Pregnancy
Cancer
Liver Disease
Bleeding Problems