New Patient Health & History Form
Full Name
*
Address
*
Email
*
SSN
*
Date of Birth
*
Age
*
Sex
*
Male
Female
Prefer not to say
Home Phone
Cell Phone
*
Relationship to Patient
Full Name
SSN
Insurance Number
Drivers License
Date of Birth
Employer
Employer Address
Emergency Contact
Additional Contact Numbers
How did you hear about us?
Please mark below:
Sign
Employee Referral
Friend / Relative
Flyers
THMP - Medicaid
Insurance / Employer
Internet Search
An Ad
Other
No elements found. Consider changing the search query.
List is empty.
Reason for Today's Visit
Date of Last Visit
Are You Nervous About Dental Treatment?
Yes
No
Do You Gums Bleed, Feel Tender, or Irritated?
Yes
No
Are You Unhappy With the Appearance of Your Teeth?
Yes
No
Are Your Teeth Sensitive?
Yes
No
Do You Have Discolored Teeth That Bother You?
Yes
No
Are You Currently Seeing A Physician?
Yes
No
The Name & Number of Your Physician
If Yes, What Is the Condition Being Treated?
Are You Taking Any Medications?
Yes
No
If Yes, Please List:
Have You or Are You Currently Taking Aspirin?
Yes
No
If Female, Are You or Do You Suspect to be Pregnant?
Yes
No
Not Applicable
If Yes, How Many Months?
Have You or Are You Currently Taking Oral Bisphosphonates?
Actonel
Boniva
Fosomax
Skelif
Didrone
Other
If Other:
Have You Had Any Joint Replacements?
Yes
No
If Yes, When?
Is There Anything Else We Should Know About Your Health That Was Not Covered On This Form?
Yes
No
If Yes, Please Explain:
Please Mark Any of the Following Which You Have Had or Have At Present:
Heart Disease
Heart Murmur
High Blood Pressure
Blood Disease
Rheumatic Fever
Venereal Disease
Asthma
Anemia
Kidney Trouble
Bone Loss
Epilepsy or Seizures
Ulcers
Emphysema
Tuberculosis
Scarlet Fever
Nervousness
Thyroid Disease
Chemo: (Cancer, Leukemia)
Arthritis
Rheumatism
Cortisone Medicine
Joint Replacement
Hay Fever
HIV + Aids
Hepatitis
Hemophilia
Sickle Cell Disease
Bruise Easily
Pain in Jaw Joint
Diabetes
Glaucoma
NONE
Please Mark Any of the Following Medical Allergies:
Local Anesthetics
Aspirin
Iodine
Penicillin
Other Antibiotic
Sulfa Drugs
Codeine or other Narcotics
Barbiturates or Sedatives
Latex
Fen-Phen
Other
Other Allergies:
Signature of Patient/Parent/Guardian
Clear
