Medical History New Patient
Medical History for New Patient
Psychiatric Treatment
Heart Murmur
Sinus Trouble
Heart Trouble
Diabetes
Bleeding Problems
Liver Disease
Cancer
Pregnancy
Kidney Disease
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 dentist
City/State
Date of last cleaning and exam
Reason for today`s visit
Unusual reaction to dental injections?
High Blood Pressure
Ulcers
Stroke
Joint Replacement
Rheumatic Fever
Tobacco use? If so, what kind and how much?
Date: 5/10/2024
Are you allergic to any of the following?
Y
N
Y
N
Last Name:
First Name:
Birthdate:
Name of Medical Doctor:
City/State:
Emergency Contact
Phone
Relationship
List all medications that you are now taking:
Ibuprofen
Sulfa
Do you have any of the following medical conditions?
Y
N
Y
N
Asthma
Penicillin
Anesthetic
Iodine
Aspirin
Latex
Codeine
Signature will be recorded later.