Medical History New Patient

We are pleased to welcome you to our office. Please take a few minutes to fill out as completely as you can. If you have any questions we will be glad to help you.
Last Name
First Name
Birthdate
Name of Medical Doctor
City/State
Emergency Contact
Phone
Relationship
List all medications that you are now taking
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Enter Medication 10
Are you allergic to any of the following?
Anesthetic
Aspirin
Codeine
Ibuprofen
Iodine
Latex
Penicillin
Sulfa
Do you have any of the following medical conditions?
Asthma
Bleeding Problems
Cancer
Diabetes
Heart Murmur
Heart Trouble
High Blood Pressure
Joint Replacement
Kidney Disease
Liver Disease
Pregnancy
Psychiatric Treatment
Sinus Trouble
Stroke
Ulcers
Rheumatic Fever
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