New Patient Form Step 1 of 5 20% About YouToday's Date MM slash DD slash YYYY Prefix Mr. Mrs. Ms. Dr. Name First Middle Initial Last I prefer to be calledGender Male Female BirthdateAgeHome Address Street Address Address Line 2 City State ZIP / Postal Code Home PhoneCell PhoneWhom may we thank for referring you?Other family member seen by usOther DentistStatus Previous Present Last Visit Date Insurance - PrimaryDental Coverage? Yes No Insurance Company NameInsurance Company AddressInsurance Company Phone NumberGroup Number (Plan, Local or Policy Number)Insured's NameRelationInsured's BirthdateInsured's ID NumberEmployer NameInsurance - SecondaryDental Coverage? Yes No Insurance Company NameInsurance Company Phone NumberInsurance Company AddressGroup Number (Plan, Local or Policy Number)RelationInsured's BirthdateInsured's ID NumberEmergency ContactNameRelationPhone Number Medical HistoryDo you have a personal physician? Yes No Physician's NamePhone NumberDate of last visitAre you currently under the care of a physician? Yes No Please explainYour current physical health Good Fair Poor Do you smoke or use tobacco in any other form? Yes No Have you had any metal rods, pins or implants? Yes No Are you taking any prescription/over-the-counter or herbal supplemental drugs? Yes No Please list each oneHave you ever taken Fosamax, or any other bisphosphonate? Yes No Have you been told that you snore or hold your breath while sleeping or wake up gasping for breath? Yes No Are you using a prescribed method of birth control? Yes No Are you pregnant? Yes No Week #?Are you nursing? Yes No Have the child ever had any of the following medical problems Abnormal Bleeding Herpes / Fever Blisters Alcohol / Drug Abuse High Blood Pressure Anemia HIV + / AIDS Arthritis Hospitalized for Any Reason Artificial Bones / Joints / Valves Kidney Problems Asthma Liver Disease Blood Transfusion Low Blood Pressure Cancer / Chemotherapy Lupus Colitis Mitral Valve Prolapse Congenital Heart Defect Osteoporosis / Paget's Disease Diabetes Pacemaker Difficulty Breathing Psychiatric Treatment Emphysema Radiation Treatment Epilepsy Rheumatic / Scarlet Fever Fainting Spells Seizures Frequent Headaches Shingles Glaucoma Sickle Cell Disease / Traits Hay Fever Sinus Problems Heart Attack Stroke Heart Murmur Thyroid Problems Heart Surgery Tuberculosis (TB) Hemophilia Ulcers Hepatitis Venereal Disease Please list any other serious medical condition(s) that you have ever hadAre you allergic to any of the following? Aspirin Latex Codeine Penicillin Dental Anesthetics Tetracycline Erythromycin Other Please list any other drugs / materials that you allergic to Dental HistoryWhy have you come to the dentist today?Do you require antibiotics before dental treatment? Yes No Are you currently in pain? Yes No Have you ever had a serious / difficult problem associated with any previous dental work? Yes No Do you have fears about going to the dentist? Yes No Have you ever had gum treatment? Yes No Do you now or have you ever experienced pain / discomfort in your jaw joint (TMJ / TMD)? Yes No Your current dental health is Good Fair Poor Do you like your smile? Yes No Do your gums ever bleed? Yes No How many times a week do you floss?How many times a day do you brush?What type of bristles? Soft Medium Hard How long do you use a toothbrush before replacing it?Are your teeth sensitive to heat, cold, or anything else?Have you lost any teeth? Yes No If yes, why? I have received a copy of this office's Notice of Privacy PracticesAcknowledgement of receipt of Privacy Practices(Required) Yes I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my medical status. I have received a copy of this office's Notice of Privacy Practices.(Required)Please sign above.Date MM slash DD slash YYYY Payment is due in full at the time of treatment unless prior arrangements have been approved.I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my medical status. I have received a copy of this office's Notice of Privacy Practices.(Required)Please sign above.Date MM slash DD slash YYYY
