Medical History New Patient
Bleeding Problems
Liver Disease
Cancer
Pregnancy
Do you have any of the following medical conditions?
Y
N
Kidney Disease
Y
N
Asthma
Heart Trouble
Stroke
High Blood Pressure
Ulcers
Diabetes
Psychiatric Treatment
Heart Murmur
Sinus Trouble
List all medications that you are now taking:
Birthdate:
Name of Medical Doctor:
City/State:
Medical History for New Patient
Last Name:
First Name:
Phone
Relationship
Emergency Contact
Codeine
Penicillin
Ibuprofen
Sulfa
Latex
Y
N
Anesthetic
Are you allergic to any of the following?
Y
N
Aspirin
Iodine
Joint Replacement
Do you have BiteWing x-rays that are less than 1 year old?
Name of former dentist
New patients:
Do you have a Panoramic x-ray or Full Mouth x-rays that are less than 5 years old?
Date of last cleaning and exam
Date: 3/28/2024
City/State
Tobacco use? If so, what kind and how much?
Rheumatic Fever
Reason for today`s visit
Are you in pain?
Unusual reaction to dental injections?
Signature will be recorded later.