Medical History New Patient
Heart Murmur
Diabetes
Psychiatric Treatment
Heart Trouble
Sinus Trouble
Liver Disease
Kidney Disease
Bleeding Problems
Pregnancy
Cancer
Stroke
Do you have a Panoramic x-ray or Full Mouth x-rays that are less than 5 years old?
New patients:
Do you have BiteWing x-rays that are less than 1 year old?
Reason for today`s visit
Are you in pain?
Date of last cleaning and exam
Signature will be recorded later.
Date: 4/18/2024
Name of former dentist
City/State
Ulcers
High Blood Pressure
Tobacco use? If so, what kind and how much?
Rheumatic Fever
Unusual reaction to dental injections?
Joint Replacement
Y
N
Y
N
Are you allergic to any of the following?
Name of Medical Doctor:
City/State:
Last Name:
Medical History for New Patient
Birthdate:
First Name:
Relationship
List all medications that you are now taking:
Emergency Contact
Phone
Ibuprofen
Sulfa
Penicillin
Do you have any of the following medical conditions?
Asthma
Y
N
Y
N
Iodine
Aspirin
Anesthetic
Codeine
Latex