New Patient Information Form

 

Please complete the following form online to expedite your visit to our center

Personal Information
Date:
First Name: Last Name:
Age: Birthdate: If Child, Parent Name:
Social Security #:

Home Address:
City: State: Zip Code:
Home Telephone (with area code):

Employed By:
Occupation: How Long?:
Work Address:
City: State: Zip Code:
Work Telephone (with area code):

Emergency Contact
Name:
Relationship: Phone Number:

Name of Spouse:
Employed By:
Occupation: How long?:
Work Address:
City: State: Zip Code:
Work Telephone (with area code):

Medical Information
Name of Dentist: How long?:
Specialty: Phone Number:
Name of Physician: How long?:
Specialty: Phone Number:
Patient Referred By:
Reason for Visit:

DENTAL HISTORY

The following questions are associated with the proper management of your oral health.


Date of last dental visit: For what?
Reason for referral to PermaDent:
Comments:

Are you presently in pain? YES NO

If yes, check all that apply: Teeth Gums Jaw Face


Is any part of your mouth sensitive to: YES NO

If yes, check all that apply: Hot Cold Sweet Pressure


Have you ever been informed that you have gum problems? YES NO
Have you ever had periodontal treatment? YES NO
Are you aware of clenching or grinding your teeth? YES NO

Have you ever had an unfavorable reaction to local anesthetic? YES NO

If yes, explain:


Have you ever had any trouble with any previous dental treatment? YES NO

If yes, explain:


dental_treatment_nervous YES NO

If yes, check one: Slightly Moderately Extremely


Are you dissatisfied with the appearance of your teeth? YES NO

If yes, what would you most like to change?


Any other comments regarding your smile, teeth, or facial characteristics?


HEALTH HISTORY
The following questions are associated with the proper management of your oral health.

Are you in good health? YES NO

If no, what is nature of illness?


Date of last physical examination: Height: Weight:

Blood Pressure:


Are you being treated by a physician now? YES NO

If yes, what for?


Are you taking any drugs or medication? YES NO

If yes, what?


Have you had excessive bleeding requiring special treatment? YES NO

If yes, describe:


Have you ever had any serious injury or surgery? YES NO

If yes, describe:


Do you have a cardiac pacemaker or any internal prosthetic device? YES NO

If yes, specify:


Have you ever had radiation treatment or chemotherapy drugs? YES NO

If yes, specify:


Have you ever had any of the following conditions?
Rheumatic Fever YES NO Respiratory Disorder YES NO
Heart Disease YES NO Tuberculosis YES NO
Heart Murmur YES NO Asthma YES NO
Mitral Value Prolapse YES NO Liver Disorder YES NO
Stroke YES NO Kidney Disorder YES NO
Hi/Lo Blood Pressure YES NO Diabetes YES NO
Anemia YES NO HIV (Aids) YES NO
Arthritis YES NO Hepatitis YES NO
Osteoporosis YES NO Sinus Trouble YES NO

Do you currently have any infectious disease including venereal disease? YES NO

If yes, specify:


Has anyone in your family ever had diabetes? YES NO

If so, who?


Are you allergic to any of the following drugs?
Local Anesthetics YES NO
Epinephrine YES NO
Penicillin YES NO
Other Antibiotics YES NO
Non-Steriodial Anti-Inflammatory Drugs YES NO
Aspirin YES NO
Codeine or Other Narcotics YES NO
Other Pain Medication YES NO
Barbiturates, Sedatives, Sleeping Pills YES NO
Any Other Drugs YES NO

Do you smoke? YES NO

If yes, how much?


Do you drink alcohol? YES NO

If yes, how much?


Women: Are you pregnant? YES NO
Women: Do you take birth control pills? YES NO

(antibiotics may nullify effective contraception)


Have you ever taken 'fen-phen'? YES NO

Do you have any disease, condition, or problem not listed above that you think the doctor should know about? YES NO

If so, explain:


This completes your medical questionaire.  Please press SUBMIT to send your form to our office. To clear the contents of this form, press RESET.

 



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