New Patient Intake Form Patient Name Email Phone Birthdate Physician Physician's Phone Closest Relative Realtive's Phone Any serious problems associated with dental treatment? If yes, please explain. Any current pain? If yes, please explain. Reason for Visit Last Dental Visit Last Dental X-Ray GENERAL HEALTH HISTORY. PLEASE CHECK ALL THAT APPLY. Cardiovascular Disorders High Blood Pressure Congenital Heart Disease Rheumatic Fever Heart Murmur/Valve Problem Heart Pacemaker Vascular Graft Heart or Bypass Surgery Artificial Heart Valve Heart Attack Congestive Heart Failure Awaken With Breathing Difficulty Angina Pectoris/Chest Pain Swollen Ankles Irregular or Rapid Heart Beats Stroke Respiratory Disorders Emphysema or Asthma Hay Fever Chronic Cough or Bronchitis Tuberculosis (TB) Chronic Sinusitis Breathing Problems Musculo-Skeletal/CNS/Developmental Disorders Frequent Headaches Fainting Spells ro Loss of Consciousness Seizures or Epilepsy Visual Impairment Artificial Joint Arthritis or Bone Disease Muscle Disease Spinal Cord Injury or Paralysis Cerebral Palsy Mental Retardation/Autism Alzheimer's Disease or Other Dimentia Gastrointestinal/Genitourinary Disorders Colitis or Ulcers Hepatitis or Other Liver Disease Jaundice Renal Dialysis/Transplant Kidney Disease Syphilis, Gonorrhea or Other Sexually Transmitted Diseases Genital Herpes Frequent Canker Sores Frequent Cold Sores Chronic Diarrhea Frequent Vomiting Hematologic/Enocrine/Immune Disorders Blood Transfusion Denied Permission to Give Blood Anemia/Lukemia/Lymphoma Hemophilia Sickle Cell Disease Blood Clots or Thrombosis Diabetes Thyroid Disease Adrenal Gland Disease AIDS HIV Infection Bleeding or Bruising Tendency Sudden Weight Loss or Gain Frequent Thirst Frequent Hunger Frequent Urination Cancer/Radiotherapy Chemotherapy Systemic Lupis Psychiatric Nervousness Depression Anxiety Past/Present Psychiatric Treatment Family History (Grandparents, Parents, Siblings, Children) Diabetes Heart Disease Bleeding Disorders Allergies Penicillin Sulfa Drugs Novocaine/Xylocaine Dental Anesthetics Aspirin Codeine Latex Other Females Are you Pregnant Now Are You Practicing Birth Control Do You Anticipate Becoming Pregnant Are You Breast Feeding Now Dental History Are You Having Pain or Discomfort Related to Your Mouth? Do You Feel Nervous About Having Dental Treatment? Have You Ever Had a Bad Experience In A Dental Office? Would You Prefere Any of The Following For Dental Procedures Oral Sedation Nitrous Oxide I.V. Twilight Sleep Have You Ever Had Phen-fen? Any Medical Problems, History of Hospitalization and/or Surgical Procedures in the Last Five Years? Explain Current Medications: Prescribed and Over the Counter Medications Taken Within the Last Six Months. Including Birth Control Pills. Please Describe How We May Make Your Dental Treatment More Comfortable and Pleasant Are You Happy With The Appearance of Your Teeth? Would You Like To Improve The Appearance of Your Teeth? Submit
