New Patient Form Template

Welcome to our office. Please allow us to get to know you better by completing the following questionnaire. Thank you.

Birth defects or hereditary problems?

Y N NA

Rheumatoid or arthritic conditions?

Y N NA

Kidney problems?

Y N NA

Polio, mononucleosis, tuberculosis, or pneumonia?

Y N NA

Problems of the immune system?

Y N NA

AIDS or HIV positive?

Y N NA

Fainting spells, seizures, epilepsy, or neurological problems?

Y N NA

Recent loss of weight or poor appetite?

Y N NA

High or low blood pressure?

Y N NA

Tired easily?

Y N NA

Cardiovascular problem (heart trouble, heart attack, angina, coronary insufficiency, arteriosclerosis, stroke, inborn heart defects, heart murmur or rheumatic heart disease)?

Y N NA

Bone Fractures, or any major accidents?

Y N NA

Bone Fractures, or any major accidents?

Y N NA

Cancer, tumors, radiation, or chemotherapy?

Y N NA

Stomach ulcer, or hyper-acidity?

Y N NA

Endocrine or Thyroid problems?

Y N NA

Hepatitis, jaundice, or liver problems?

Y N NA

Mental Health disturbance or depression?

Y N NA

Vision, hearing, tasting, or speech difficulties?

Y N NA

History of eating disorders?

Y N NA

Excessive bleeding, anemia, or bleeding disorder?

Y N NA

Chest pain, shortness of breath or Swelling ankles?

Y N NA

Skin disorder?

Y N NA

Frequent headaches, colds, or sore throats?

Y N NA

Hay fever, asthma, sinus trouble or hives?

Y N NA

Tonsil, or adenoid conditions?

Y N NA

Eye, ear, nose, or throat conditions?

Y N NA

Do you have a balanced diet?

Y N NA

Osteoporosis?

Y N NA

Are you pregnant or nursing?

Y N NA

Are you anticipating becoming pregnant?

Y N NA

Are you menopausal or post-menopausal?

Y N NA

Number of brothers and sisters:

Ages:

Other family members treated:

Musical instrument played:

Patient's Birth weight:

Present weight and height:

Favorite sports, hobbies, or avocations:

Patient's school:

Grade:

Local Anesthetics

Y N NA

Asprin

Y N NA

Ibuprofen (Motrin or Advil)

Y N NA

Penicillin or other antibiotics

Y N NA

Codeine or other Narcotics

Y N NA

Codeine or other Narcotics

Y N NA

Metals (Jewelry, clothing snaps)

Y N NA

Latex (Gloves, Balloons)

Y N NA

Animals

Y N NA

Foods (Specify)

Y N NA

Other(specify)

Y N NA

Are you taking any medication, nutrient supplements, herbal medications or non-prescription medicine? Please name and list reason:

Do you smoke or chew tobacco?

Y N

Have ever had any operations or been hospitalized? Please specify

Any other physical problems or symptoms? Describe:

Are you being treated by another healthcare professional?

Y N

For:

Last visit:

"Extra" (supernumerary) teeth?

Y N NA

Congenitally missing teeth?

Y N NA

Chipped or otherwise injured teeth?

Y N NA

Sensitivity to hot/cold, throb or ache?

Y N NA

Jaw fractures, cysts, or infections?

Y N NA

Have you had any root canals?

Y N NA

Food impactions between teeth?

Y N NA

"Gum boils", frequent canker or cold sores?

Y N NA

Been treated for TMD or TMJ?

Y N NA

Any loose, broken, or missing restorations?

Y N NA

Thumb, finger or sucking habit?

Y N NA

Until the age:

Abnormal swallowing habit or tongue thrusting?

Y N NA

History of speech problems?

Y N NA

Mouth breathing, snoring, or difficulty breathing?

Y N NA

Tooth grinding or Clenching jaw?

Y N NA

Pain clicking or popping of jaw?

Y N NA

Any pain or soreness in face or ears?

Y N NA

Difficulty chewing or opening jaw?

Y N NA

Concerned about spaced, crooked, or protruding teeth?

Y N NA

Aware or concerned about underdeveloped jaw?

Y N NA

Any relatives with similar jaw relationship?

Y N NA

Had periodontal (gum) treatment?

Y N NA

Had any serious trouble associated with any previous dental treatment?

Y N NA

Been under another dentist’s care?

Y N NA

Ever had an orthodontic evaluation or treatment?

Y N NA

If yes, when? & by whom?

How often do you brush and floss?

What is your primary concern?

I h ave read, understood, the above questions and have answered to the best of my knowledge. I will not hold Mary Buatti Romeo, DDS, Karen Leavy, DDS, Scott Mateer, DDS, or David Hou, DDS responsible for any errors or omissions that I have made in the completion of this form. If there are any changes later to this history record or medical/dental status, I will inform this straight smiles.