New Patient Form

Name*

Date of Birth

Phone*

Address*

Email*

Emergency Contact

General (optional)

Are you here for an emergency?
Broken tooth
Lost filling
Toothache
Swelling
Trauma/fall
Broken denture
Other

How did you hear about us?
Recommend by someone
Seen the practice
Flyer or postcard in mail
Internet - please specify below
Referred by your dentist - please specify below
Other

Last visit
0-6 months
6-12 months
12+ months

Do you have dental anxiety?
Yes
No

Do you have any health issues you wish to discuss privately?
Yes
No

Do you have insurance?
Yes
No

Are you currently taking any medications?
Yes
No
Other

Have you been hospitalized in the last 5 years?
Yes
No

Are you allergic to any drugs, medication or latex?
Yes
No

Are you taking any of these medications:
Fosamax
Actonel
Aredi
Zometa
TPamisol
Prolia
Aspirin

Do you have an artificial hip, heart or other prosthetic implants?
Yes
No

Female patients, are you pregnant?
Yes
No

Are you a smoker?
Yes
No

Conditions
Do you have any of these conditions:
Rheumatic fever
Heart conditions surgery/stent/pacemaker
Fever
Bleeding bruising problems
Anemia
Lung problems
Tuberculosis
Digestive problems
Stomach ulcers
Liver disease
Hepatitis
kidney disease
Diabetes
Thyroid problems
Skin disease
Epilepsy
Osteoperosis
Arthritis
Bone disorders
Nervous disorders
Mental illness
Dizzy spells
Asthma
Sleep apnea
Blood pressure
Cancer / Chemo / Radio
HIV / AIDS
AIDS virus carrier
Other infectious disease
Other

Hospitalization:
Description

Submitting Questionnaire:
Note

I have completed this questionnaire to the best of my knowledge and I understand that failure to do so may place me at undue medical risk. *
Yes

Patient signature *