New Patient Information Form

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.