New Patient Form Please input the information requested before visiting our office. Please fill in as much information as posssible as this will expedite our ability to serve you at our offices. If this form is not completed on line new patients will be required to fill out this form upon thier first visit to our office. Name* Email* Home Phone* Mobile Phone* Date* Address Street Address City State / Province / Region Postal / Zip CodePRESENT AND PAST HEALTH STATUS Do you consider yourself to be in good health(1)YesNoDo not know Are you presently under a physician's care? Do you consider yourself to be in good healthYesNoDo not know Are you taking any medicine at the present time? *YesNoDo not know Have you ever had any major operations?YesNoDo not know Have you ever been seriously ill?YesNoDo not know Have you ever been hospitalized?YesNoDo not knowCARDIOVASCULAR Has a doctor ever said you had a heart murmur or heart trouble?YesNoDo not know Has a doctor ever said your blood pressure was too high or too low?YesNoDo not know Are you subject to fainting spells?YesNoDo not know Do you get out of breath easily?YesNoDo not know As a child did you have Rheumatic fever, growing pains or twitching of the limbsYesNoDo not know Have you at times had severe nose bleeds?YesNoDo not know Are your ankles often badly swollen?YesNoDo not know Have you ever had Rheumatic heart disease or Saint Vitus' dance?YesNoDo not know Do you sleep with more than one pillow?YesNoDo not knowBLOOD Have you ever had anemia?YesNoDo not know Have you ever had abnormal bleeding or severe pain following extraction of teeth or from a cut?YesNoDo not know Have you ever tested positive for HIV, or do you have AIDS?YesNoDo not know Do you bruise easily?YesNoDo not knowENDOCRINE Have you ever had diabetes?YesNoDo not know Has any member of your family had diabetes?YesNoDo not know Do you have trouble with frequent boils?YesNoDo not know Have you ever taken thyroid tablets?YesNoDo not know Have you ever received treatment for any type of endocrine or glandular disorder?YesNoDo not know Are you thirsty much of the time and do you drink a lot of liquids?YesNoDo not knowNERVOUS Do you suffer frequent severe headaches?YesNoDo not know Have you ever had any severe pains of the face or head?YesNoDo not know Are you under tension?YesNoDo not know Has a physician ever told you that you had epilepsy?YesNoDo not know Have you ever had a nervous breakdown?YesNoDo not knowRESPIRATORY Do you suffer from frequent colds, sore throats, or sinusitis?YesNoDo not know Have you ever had tuberculosis?YesNoDo not know Have you a persistent cough?YesNoDo not know Do you breathe primarily through your mouth?YesNoDo not knowG.I. AND G.U. Do you suffer from stomach trouble?YesNoDo not know Have you ever had yellow jaundice or hepatitis?YesNoDo not know Have you ever had liver or gall bladder trouble?YesNoDo not know Do you have kidney or bladder trouble?YesNoDo not know Are you on any special type of diet?YesNoDo not knowALLERGIES Are you sensitive or allergic to any particular medicine?(Aspirin, Antibiotics, Penicillin, Anesthetics, Novocain)?YesNoDo not know Do you have asthma or hay fever?YesNoDo not know Have you ever had hives or a rash?YesNoDo not knowOTHER Have you ever been treated for a skin disease?YesNoDo not know Are your joints often painful or swollen, do you have arthritis?YesNoDo not know Have you gained or lost much weight recently?YesNoDo not know Do you have frequent fever blisters, canker sores or have you ever had burning of the tongue or mouth?YesNoDo not know Have you ever had syphilis or gonorrhea?YesNoDo not know Have you ever received X-ray or Radioactive Isotope treatment?YesNoDo not know Have you ever had anesthesia?YesNoDo not know Have you had any X-rays taken recently?YesNoDo not knowFEMALES Are you pregnant now or suspect you may be?YesNoDo not know Is your menstrual cycle regular?YesNoDo not know Do you bleed excessively during your menstrual period?YesNoDo not know Have you ever noticed any spotting with blood or bleed in between periods?YesNoDo not know Have you undergone or are you undergoing menopause, if so, are there any symptoms?YesNoDo not knowDENTAL Have you ever had an acute sore mouth?YesNoDo not know Do you have frequent fever blisters on your lips or mouth?YesNoDo not know Have you ever had burning of the tongue or cracking of the corners of your mouth?YesNoDo not know Do your gums bleed?YesNoDo not know Are you aware of a bad taste or odor in your mouth?YesNoDo not know Are you troubled with frequent gum boils?YesNoDo not know Do you ever have pain opening or closing your mouth?YesNoDo not know Did you ever wear braces for straightening your teeth?YesNoDo not know Have you ever had previous "gum treatments"?YesNoDo not know Are you bothered by tooth sensitivity?YesNoDo not knowINSURANCE INFORMATION IF APPLICABLE Social Security Number Employer Insurance Company Group Insurance Company Policy Insurance Company PhoneCOMMENTS Are there any additional comments you would like to make concerning any recent illness, operations, medications, examinations, or your physical health in general?SubmitReset
