Medical History New Patient Alisal
Unexplained weight loss
Often exhausted or fatigued
Artificial Heart Valve
Lumps or swelling in the mouth
Describe any current medical treatment, impending surgery, genetic/development delay, or other treatment thay may possibly affect your dental treatment.
Osteoporosis (list medications)
Hepatitis Type
STI/STD/HPV
Viral Infection/Cold Sores
Shortness of Breath
Head or Neck Injuries
Pacemaker
Radiation Therapy
Arthritis
Breathing or Sleep Problems
Anemia
Autoimmune Disease
Tumor, abnormal growth
Chemical Dependency Type-
HIV/AIDS
Thyroid Disease
Low Blood Pressure
Medical History for New Patient
Psychiatric Treatment
Heart Murmur
Sinus Trouble
Heart Trouble/Problems
Diabetes Type-
Bleeding Problems (prolonged)
Liver Disease
Cancer Type-
Pregnancy
Kidney Disease
Neurologic Disorders (ADD/ADHD, etc)
Cognitive Disorders
Anxiety
Chemotherapy
Headaches
High Blood Pressure
Ulcers
Stroke
Joint Replacement (hip/knee, etc)
Rheumatic Fever/Scarlet Fever
Date: 5/12/2024
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 (one per line):
Other allergy
Sulfa
Do you have any of the following medical conditions?
Y
N
Y
N
Asthma
Penicillin
Anesthetic/Epinephrine
Iodine
Aspirin
Latex
Codeine
Signature will be recorded later.