New Patient Form

Email:
Today’s Date:
Date Format: MM slash DD slash YYYY
As required by law, our office adheres to written policies and procedures to protect the privacy of information about you that we create, receive or maintain. Your answers are for our records only and will be kept confidential subject to applicable laws. Please note that you will be asked some questions about your responses to this questionnaire and there may be additional questions concerning your health. This information is vital to allow us to provide appropriate care for you. This office does not use this information to discriminate.
Patient Information
Name:
First Middle Last
Home Phone:
Business/Cell Phone:
Zip:
Address:
City:
State:
Occupation:
Height:
Weight:
Date of Birth:
Date Format: MM slash DD slash YYYY
Sex
- M
- F
SS# or Patient ID:
Emergency Contact:
Relationship:
Home Phone:
Cell Phone:
If you are completing this form for another person, what is your relationship to that person?
Name:
First Middle Last
Relationship:
Do you have any of the following diseases or problems: (Check DK if you Don’t Know the answer to the the question)
Yes No DK
Active Tuberculosis
Persistent cough greater than a 3 week duration
Cough that produces blood
Been exposed to anyone with tuberculosis
If you answer yes to any of the 4 items above, please stop and return this form to the receptionist.
Dental Information For the following questions, please mark (X) your responses to the following questions.

Dental Information

For the following questions, please mark (X) your responses to the following questions

	Yes	No	DK
Do your gums bleed when you brush or floss?
Are your teeth sensitive to cold, hot, sweets or pressure?
Is your mouth dry?
Have you had any periodontal (gum) treatments?
Have you ever had orthodontic (braces) treatment?
Have you had any problems associated with previous dental treatment?
Is your home water supply fluoridated?
Do you drink bottled or filtered water?
If yes, how often? Circle one: DAILY / WEEKLY / OCCASIONALLY Are you currently experiencing dental pain or discomfort?
Do you have earaches or neck pains?
Do you have any clicking, popping or discomfort in the jaw?
Do you brux or grind your teeth?
Do you have sores or ulcers in your mouth?
Do you wear dentures or partials?
Do you participate in active recreational activities?
Have you ever had a serious injury to your head or mouth?

Date of your last dental exam: What was done at that time?
Date of last dental x-rays:
What is the reason for your dental visit today?
How do you feel about your smile?
Medical Information Please mark (X) your response to indicate if you have or have not had any of the following diseases or problems.
Medical Information Please mark (X) your response to indicate if you have or have not had any of the following diseases or problems.
Yes No DK
Are you now under the care of a physician?
Physician Name:
Phone:
Address/City/State/Zip:
Medical Information
Yes No DK
Are you in good health?
Has there been any change in your general health within the past year?
If yes, what condition is being treated?
Date of last physical exam:
Medical Information
Yes No DK
Have you had a serious illness, operation or been hospitalized in the past 5 years?
If yes, what was the illness or problem?
Medical Information
Yes No DK
Are you taking or have you recently taken any prescription or over the counter medicine(s)?
If so, please list all, including vitamins, natural or herbal preparations and/or dietary supplements:
Medical Information Please mark (X) your response to indicate if you have or have not had any of the following diseases or problems.
(Check DK if you Don’t Know the answer to the question)
Please mark (X) your response to indicate if you have or have not had any of the following diseases or problems.
Yes No DK
Do you wear contact lenses?
Medical Information
Yes No DK
Joint Replacement. Have you had an orthopedic total joint (hip, knee, elbow, finger) replacement?
Date:
Date Format: MM slash DD slash YYYY
If yes, have you had any complications?
Medical Information
Yes No DK
Are you taking or scheduled to begin taking an antiresorptive agent (like Fosamax® , Actonel® , Atelvia, Boniva® , Reclast, Prolia) for osteoporosis or Paget’s disease?

	Yes	No	DK
Are you now under the care of a physician?

	Yes	No	DK
Have you had a serious illness, operation or been hospitalized in the past 5 years?

	Yes	No	DK
Are you taking or have you recently taken any prescription or over the counter medicine(s)?

	Yes	No	DK
Do you wear contact lenses?

	Yes	No	DK
Joint Replacement. Have you had an orthopedic total joint (hip, knee, elbow, finger) replacement?

	Yes	No	DK
Are you taking or scheduled to begin taking an antiresorptive agent (like Fosamax® , Actonel® , Atelvia, Boniva® , Reclast, Prolia) for osteoporosis or Paget’s disease?

Medical Information

	Yes	No	DK
Since 2001, were you treated or are you presently scheduled to begin treatment with an antiresorptive agent (like Aredia® , Zometa® , XGEVA) for bone pain, hypercalcemia or skeletal complications resulting from Paget’s disease, multiple myeloma or metastatic cancer?

Date Treatment began:
Medical Information
Yes No DK
Do you use controlled substances (drugs)?
Medical Information
Yes No DK
Do you use tobacco (smoking, snuff, chew, bidis)?
Medical Information
VERY SOMEWHAT NOT INTERESTED
If so, how interested are you in stopping?
Medical Information
Yes No DK
Do you drink alcoholic beverages?
If yes, how much alcohol did you drink in the last 24 hours?
If yes, how much do you typically drink i n a week?
WOMEN ONLY Are you:
WOMEN ONLY Are you:
Yes No DK
Pregnant?
Taking birth control pills or hormonal replacement?
Nursing?
Number of weeks:
Allergies. Are you allergic to or have you had a reaction to: To all yes responses, specify type of reaction.
Allergies. Are you allergic to or have you had a reaction to: To all yes responses, specify type of reaction.
Yes No DK
Local anesthetics
Aspirin
Penicillin or other antibiotics
Barbiturates, sedatives, or sleeping pills
Sulfa drugs
Codeine or other narcotics
Allergies. Are you allergic to or have you had a reaction to: To all yes responses, specify type of reaction.
Yes No DK
Metals
Latex (rubber)
Iodine
Hay fever/seasonal
Animals
Food
Other

	Yes	No	DK
Do you use controlled substances (drugs)?

	Yes	No	DK
Do you use tobacco (smoking, snuff, chew, bidis)?

	VERY	SOMEWHAT	NOT INTERESTED
If so, how interested are you in stopping?

	Yes	No	DK
Do you drink alcoholic beverages?

Please mark (X) your response to indicate if you have or have not had any of the following diseases or problems.

	Yes	No	DK
Artificial (prosthetic) heart valve
Previous infective endocarditis
Damaged valves in transplanted heart
Congenital heart disease (CHD)
Unrepaired, cyanotic CHD
Repaired (completely) in last 6 months
Repaired CHD with residual defects

Except for the conditions listed above, antibiotic prophylaxis is no longer recommended for any other form of CHD.

	Yes	No	DK
Cardiovascular disease
Angina
Arteriosclerosis
Congestive heart failure
Damaged heart valves
Heart attack
Heart murmur
Low blood pressure
High blood pressure
Other congenital heart defects
Mitral valve prolapse
Pacemaker
Rheumatic fever
Rheumatic heart disease
Abnormal bleeding
Anemia
Blood transfusion
Hemophilia
AIDS or HIV infection
Arthritis

	Yes	No	DK
Autoimmune disease
Rheumatoid arthritis
Systemic lupus erythematosus
Asthma
Bronchitis
Emphysema
Sinus trouble
Tuberculosis
Cancer/Chemotherapy/ Radiation Treatment
Chest pain upon exertion
Chronic pain
Diabetes Type I or II

Yes No DK
Eating disorder
Malnutrition
Gastrointestinal disease
G.E. Reflux/persistent heartburn
Ulcers
Thyroid problems
Stroke
Glaucoma
Hepatitis, jaundice or liver disease
Epilepsy
Fainting spells or seizures

12280 Miramar Blvd St. #2

Call us Today

Opening Hours

Book Appointment

Patient Information

Dental Information For the following questions, please mark (X) your responses to the following questions.

Dental Information

Medical Information Please mark (X) your response to indicate if you have or have not had any of the following diseases or problems.

Medical Information Please mark (X) your response to indicate if you have or have not had any of the following diseases or problems.

Medical Information Please mark (X) your response to indicate if you have or have not had any of the following diseases or problems.

12280 Miramar Blvd St. #2

Call us today!

Opening Hours

Booking Appointment

Opening Hours

Social Media

	Yes	No	DK
Active Tuberculosis
Persistent cough greater than a 3 week duration
Cough that produces blood
Been exposed to anyone with tuberculosis

	Yes	No	DK
Are you in good health?
Has there been any change in your general health within the past year?

	Yes	No	DK
Pregnant?
Taking birth control pills or hormonal replacement?
Nursing?

	Yes	No	DK
Local anesthetics
Aspirin
Penicillin or other antibiotics
Barbiturates, sedatives, or sleeping pills
Sulfa drugs
Codeine or other narcotics

	Yes	No	DK
Metals
Latex (rubber)
Iodine
Hay fever/seasonal
Animals
Food
Other

	Yes	No	DK
Eating disorder
Malnutrition
Gastrointestinal disease
G.E. Reflux/persistent heartburn
Ulcers
Thyroid problems
Stroke
Glaucoma
Hepatitis, jaundice or liver disease
Epilepsy
Fainting spells or seizures