Medical History New Patient
City/State
Name of former dentist
Do you have BiteWing x-rays that are less than 1 year old?
New patients:
Do you have a Panoramic x-ray or Full Mouth x-rays that are less than 5 years old?
Are you in pain?
Unusual reaction to dental injections?
Tobacco use? If so, what kind and how much?
Rheumatic Fever
Joint Replacement
Ulcers
High Blood Pressure
Stroke
Heart Trouble
Sinus Trouble
Heart Murmur
Psychiatric Treatment
Diabetes
Pregnancy
Cancer
Liver Disease
Bleeding Problems
Kidney Disease
Asthma
Y
N
N
Y
Do you have any of the following medical conditions?
Sulfa
Ibuprofen
Penicillin
Codeine
Latex
Aspirin
Iodine
Anesthetic
N
N
Y
Y
Are you allergic to any of the following?
List all medications that you are now taking:
Relationship
Phone
Emergency Contact
City/State:
Name of Medical Doctor:
Birthdate:
First Name:
Last Name:
Medical History for New Patient
Date of last cleaning and exam
Date: 4/24/2024
Signature will be recorded later.