New Patient Form | Periodontics
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New Patient Form

Please fill out the following form
in order to expedite your appointment.

Gender
Medical History

Mark the corresponding box next to any of the following illnesses you have had:

Mark the corresponding box next to any of the following medications you are taking or have a reaction to:

Please list the name(s) of the medications and dosage:

Do you smoke?
Do you consume alcoholic beverages?
Do you have skin problems?
Have you or any member of your family ever had bleeding problems?
Have you had prolonged bleeding afte surgery or tooth extraction?
Have you ever had convulsions or fainting spells?
Do you wake with unusual thirst or need to urinate?
Do you have headaches more than twice a week?
Do you have any cardivascular disease (heart trouble, heart attack, coronary insufficiency, coronary occlusion)?
Have you been bothered by a thumping or racing heart?
Does very little effort leave you short of breath?
Do you have damaged heart valves or artificial heart valves?
Have you ever been told you have a heart murmor?
Have you ever had surgery or radiation treatment for a tumor or growth?
Have you been under a physician's care within the last year?
Are you now under the care of a physician?
Have you ever been hospitalized for any serious medical iillness or operation?
Have you ever had a prosthetic implanted (heart valve, joint. replacement)?
Do your gums ever bleed when you brush your teeth?
Do you ever have bad taste in your mouth?
Are your gums receding (root exposure)?
Are your teeth sensitive to hot or cold?
Do you suffer from pain and/or swelling of your gums (abcesses)?
Have you noticed any loosening of you teeth?
Do you ever find yourself clenching and/or grinding your teeth?
Have you ever had a bad reaction to dental anesthetic (Novacaine)?
Have you ever had any complications following dental surgery?
Do you gag easily?
Do you have trouble relaxing during a dental visit?
Do you use:

For Women Only

Are you presently taking birth control?
Have you gone through or are presently going through menopause?
Are you pregnant or trying to become pregnant at the present time?

Insurance Information

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Comments

I understand that if I cancel an appointment without giving at least twenty-four (24) hours notice I will be billed $50. I agree to pay this broken appointment fee within 30 days of the date of the broken appointment.

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I certify that the above health history is accurate and I will notify you of any change in my physical condition.

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