New Patient Form

Mr.Mrs.Ms.Dr.

Gender:
MaleFemale

Employer

Referred By (Dentist/Orthodontist)

Medical Doctor*

Marital Status*

Emergency Contact*

Emergency Contact Phone*

Relation*

Parent Or Guardian Responsible For Patient

Self (If self, skip this section)SpouseFatherMotherOther

Other

Employer

Your medical history is important to the treatment you will receive. Therefore, it is important that you respond to each question honestly and completely.

Please describe your current health:
ExcellentGoodFairPoor

Have there been any changes in your general health in the past year?
YesNo

Are you now under a doctor’s care for a particular problem at this time?
YesNo

Have you ever been hospitalized or had a serious illness?
YesNo

Have you ever had surgery?
YesNo

Patient Medical History

Do you have or have you ever had:

Congenital heart disease, cardiovascular disease, heart attack, heart murmur, coronary artery disease, chest pain, high/ low blood pressure, stroke, irregular heartbeat, heart surgery, pacemaker?
YesNo

Lung disease, asthma, emphysema, COPD, chronic cough, bronchitis, pneumonia, tuberculosis, shortness of breath, chest pain, severe coughing?
YesNo

Implants placed anywhere in the body (heart valve, pacemaker, hip, knee)?
YesNo

Bleeding disorder, anemia, bleeding tendency, blood transfusion? Do you bruise easily?
YesNo

Kidney disease or kidney failure, requiring dialysis?
YesNo

Liver disease (jaundice, hepatitis A, B, or C)?
YesNo

Thyroid disease?
YesNo

Arthritis
YesNo

Stomach ulcers, acid reflux colitis?
YesNo

Significant weight loss or gain?
YesNo

Clicking, popping, or pain within the jaw joint and/or difficulty opening mouth?
YesNo

Seizures, convulsions, epilepsy, fainting or dizziness?
YesNo

Frequent or recurring mouth sores?
YesNo

Sinus or nasal problems?
YesNo

Glaucoma?
YesNo

Sleep apnea?
YesNo

Diabetes?
YesNo

Osteoporosis or osteopenia?
YesNo

Any cancer, radiation, or chemotherapy?
YesNo

Do you have any other disease, condition or problem not listed above that you think the doctor should know about?
YesNo

Are you pregnant, or is there any chance you might be pregnant? (FEMALE PATIENTS)
YesNo

Medications

Are you using any of the following:

Antibiotics?
YesNo

Prescription pain medication?
YesNo

Anticoagulants (blood thinners)?
YesNo

Aspirin or drugs such as Motrin, Aleve, Ibuprofen?
YesNo

Heart medications?
YesNo

Insulin or oral anti-diabetic drugs?
YesNo

Steroids (cortisone, prednisone, etc.)?
YesNo

Blood pressure medications?
YesNo

Antianxiety agents, antidepressants or other psychiatric medications?
YesNo

Bisphosphonates, medications to strengthen your bones, IV medications, or any other cancer drugs?
YesNo

Allergies

Are you allergic to or have you had an adverse reaction to:

Latex?
YesNo

Food allergies (nuts, eggs)?
YesNo

Sedatives, barbiturates?
YesNo

Codeine or other pain killers?
YesNo

Aspirin, Motrin, Aleve, or ibuprofen?
YesNo

Penicillin or other antibiotics?
YesNo

Have you or an immediate family member had any problem associated with local anesthesia, general anesthesia, and/or intravenous sedation?
YesNo

Social History

Have you ever smoked, vaped or chewed tobacco?
YesNo

Have you ever sought professional care or been hospitalized for:

Substance abuse?
YesNo

Emotional disorders?
YesNo

Alcoholism?
YesNo

Do you use:

Alcohol?
YesNo

Marijuana?
YesNo

Recreational drugs?
YesNo

Dental History

Have you had any adverse effects from dental treatment?
YesNo

Do you wish to talk to the doctor privately about anything?
YesNo

Family Medical History

Do you have a family history of any of the following? If yes, indicate the relationship.

Diabetes?
YesNo

Cancer?
YesNo

Heart disease?
YesNo

Bleeding problems?
YesNo

Sleep Apnea?
YesNo

Lung disease?
YesNo

Insurance Information

Please present your medical and dental insurance cards at your appointment. If complete insurance information is not provided at time of service, payment will be expected in full.

Dental Insurance

Primary Insurance

Secondary Insurance

Medical Insurance

Primary Insurance

Secondary Insurance

I understand the importance of a truthful and complete health history to assist my doctor in providing the best care possible. To the best of my knowledge, the above information is complete and correct.

Signature of patient, parent, guardian*

I authorize Dr. Lisa Miller and team to perform an oral and maxillofacial examination for the aim of diagnosing and treatment planning. Furthermore, I authorize the taking of all x-rays needed as a necessary a part of this examination. Additionally, if medically necessary, I authorize the discharge of any data obtained within the course of my examination and treatment to my alternative doctors and/or insurance carriers.

Signature of patient, parent, guardian*