Medical History for New PatientLast Name:First Name:Birthdate:Name of Medical Doctor:City/State:Emergency ContactPhoneRelationshipList all medications that you are now taking:Are you allergic to any of the following?YNYNAnestheticIodineAspirinLatexCodeinePenicillinIbuprofenSulfaDo you have any of the following medical conditions?YNYNAsthmaKidney DiseaseBleeding ProblemsLiver DiseaseCancerPregnancyDiabetesPsychiatric TreatmentHeart MurmurSinus TroubleHeart TroubleStrokeHigh Blood PressureUlcersJoint ReplacementRheumatic FeverTobacco use? If so, what kind and how much?Unusual reaction to dental injections?Are you in pain?New patients:Do you have a Panoramic x-ray or Full Mouth x-rays that are less than 5 years old?Do you have BiteWing x-rays that are less than 1 year old?Name of former dentistCity/StateDate of last cleaning and examDate: 12/15/2018
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