Medical History New Patient_New
Last Name
Last Name is a required field
First Name
First Name is a required field
Invalid Date of Birth. Format MM/dd/yyyy
Birthdate
Birthdate is a required field
Name of Medical Doctor
City/State
Emergency Contact
Phone
Relationship
List all medications that you are now taking
Enter Medication 1
Enter Medication 2
Enter Medication 3
Enter Medication 4
Enter Medication 5
Enter Medication 6
Enter Medication 7
Enter Medication 8
Enter Medication 9
Enter Medication 10
Are you allergic to any of the following?
Anesthetic
Yes
No
Aspirin
Yes
No
Codeine
Yes
No
Ibuprofen
Yes
No
Iodine
Yes
No
Latex
Yes
No
Penicillin
Yes
No
Sulfa
Yes
No
Do you have any of the following medical conditions?
Asthma
Yes
No
Bleeding Problems
Yes
No
Cancer
Yes
No
Diabetes
Yes
No
Heart Murmur
Yes
No
Heart Trouble
Yes
No
High Blood Pressure
Yes
No
Joint Replacement
Yes
No
Kidney Disease
Yes
No
Liver Disease
Yes
No
Pregnancy
Yes
No
Psychiatric Treatment
Yes
No
Sinus Trouble
Yes
No
Stroke
Yes
No
Ulcers
Yes
No
Rheumatic Fever
Yes
No
Tobacco use? If so, what kind and how much?
Unusual reaction to dental injections?
Reason for today's visit
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