Schedule an Appointment

Patient's Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date of Last Visit

MM

DD

YYYY

Birth Date

MM

DD

YYYY

Home Phone

(###)

###

####

Work Phone

(###)

###

####

Sex

Male

Female

If female, please answer the following

check all that apply

Taking birth control pills

Pregnant

Nursing

Do you smoke or use tobacco?

Yes

No

Conditions

Please check all that apply

Abnormal Bleeding

Allergies

Alzheimer's Disease

Anemia

Angina Pectoris

Arthritis

Artificial Bones

Artificial Heart Valve

Asthma

Blood Transfusion

Bruise Easily

Cancer-Chemotherapy

Chest Pain

Congenital Heart Defect

Diabetes

Difficulty Breathing

Drug Abuse

Emphysema

Epilepsy

Excessive Thirst / Dry Mouth

Fainting Spells

Frequent Headaches

HIV+ AIDS

Hay Fever

Heart Attack

Heart Murmur / Irregular Heartbeat

Heart Surgery

Hemophilia

Hepatitis A

Hepatitis B

Hepatitis C

High Blood Pressure

Kidney Problems

Liver Disease

Low Blood Pressure

Mitral Valve Prolapse

Nervous / Anxious

Pace Maker

Pneumocystitis

Psychiatric Problems

Radiation Therapy

Rheumatic Fever

Seizures

Sensitive Teeth

Shingles

Sickle Cell Disease

Sinus Problems

Stroke

Thyroid Problems

Trouble Sleeping

Tuberculosis

Ulcers

Allergies

Please check all that apply

Aspirin

Codeine

Dental Anesthetics

Erythromycin

Jewelry

Latex

Metals

Penicillin

Tetracycline

Are you having dental pain or discomfort at this time!

Yes

No

Do you feel nervous about having dental treatment?

Yes

No

Have you ever had a bad experience in a dental office?

Yes

No

Do you wear removable partial or complete dentures?

Yes

No

Have you lost teeth?

Yes

No

Do you experience:

Please check any that apply

Bleedings gums

Food collects between teeth

Unpleasant taste

Teeth sensitive to sweets

Teeth sensitive to extreme temperatures

Teeth sensitive when chewing