New Patient Form Salutation: MrMrsMsDr Dental Insurance YesNo Is another member of your family a patient at our office YesNo Any Heart Problems YesNo Blood Pressure YesNo Artificial Joints YesNo Rheumatic Fever YesNo Circulatory Problems YesNo Radiation Treatment YesNo Excessive Bleeding YesNo Excessive Bruising YesNo Ulcers (stomach) YesNo Sinus Trouble YesNo Artificial Heart Valves YesNo Infectious Diseases YesNo Allergies to Anaesthetics YesNo Allergies to Penicillin YesNo Allergies to Medications YesNo Allergies to Latex YesNo Anaemia or other Blood Disorders YesNo Diabetes YesNo Asthma YesNo Hepatitis YesNo Epilepsy YesNo Liver or Kidney Problems YesNo Tumour/Cancer History YesNo Hormone Replacement Therapy YesNo Are you currently taking any drugs or medicines? YesNo Does your jaw "click" or hurt? YesNo Do you feel you grind your teeth? YesNo Have you ever had orthodontic treatment? YesNo Do you wear a dental night guard? YesNo Have you ever had periodontal (gum) treatment? YesNo Have you ever had your bite adjusted? YesNo Do you bite your lips or cheeks often? YesNo Do you smoke? YesNo Do you think you have occasional bad breath? YesNo Do your gums ever bleed when you clean your teeth? YesNo Do you experience sensitivity with hot/cold? YesNo Do your teeth ever hurt when you bite hard? YesNo Does floss ever tear between your teeth? YesNo Does food get jammed between your teeth? YesNo Is there anything else you would like us to know? YesNo Are you pregnant? YesNo How long since your last dental appointment? How often do you have dental examinations? Less than MonthlyMonthly3 Monthly6 MonthlyYearly2 YearlyGreater than 2 years Previous dental x-rays were taken Less than 1 yearMore than 1 year
