Medical History New Patient
Medical History for New Patient
Last Name:
First Name:
Birthdate:
Name of Medical Doctor:
City/State:
Emergency Contact
Phone
Relationship
List all medications that you are now taking:
Are you allergic to any of the following?
Y
N
Y
N
Anesthetic
Iodine
Aspirin
Latex
Codeine
Penicillin
Ibuprofen
Sulfa
Do you have any of the following medical conditions?
Y
N
Y
N
Asthma
Kidney Disease
Bleeding Problems
Liver Disease
Cancer
Pregnancy
Diabetes
Psychiatric Treatment
Heart Murmur
Sinus Trouble
Heart Trouble
Stroke
High Blood Pressure
Ulcers
Joint Replacement
Rheumatic Fever
Tobacco 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 dentist
City/State
Date of last cleaning and exam
Date: 4/18/2024
Signature will be recorded later.