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Do you have/Have you ever had, any of the following:
Allergy - Aspirin Allergy - Codeine Allergy - Iodine Allergy - Latex
Allergy - Penicillin Allergy - Sulpha Allergy - Amoxicillin Allergy - Erythromicin
Allergy - Local Anaesthesia Anemia Arthritis Artificial Joints
Asthma Blood Disease Cancer Cold Sores
Contraceptive Use Diabetes Dizziness/Fainting Emphysema
Epilepsy Excessive Bleeding Excessive Bruising Gastro-Intestinal
Glaucoma Hard to freeze Hay Fever High Blood Pressure
Head Injury Hearing Disabled Heart Disease Heart Murmur
Hepatitis A Hepatitis B Hepatitis C HIV / AIDS
Hives Jaundice Kidney Disease Low Blood Pressure
Liver Disease Mental Disorders Multiple Sclerosis Nervous Disorders
Pacemaker Pregnancy Radiation Treatment Respiratory Problems
Rheumatic Fever Rheumatism Rheumatoid Arthritis Sinus Problems
Skin Rash STD Stomach Problems Stroke
Thyroid Disease TMJ or TMD Tuberculosis Tumors
Ulcers
Allergy - Codeine
Allergy - Sulpha
Anemia
Blood Disease
Diabetes
Excessive Bleeding
Hard to freeze
Hearing Disabled
Hepatitis B
Jaundice
Mental Disorders
Pregnancy
Rheumatism
STD
TMJ or TMD
Allergy - Iodine
Allergy - Amoxicillin
Arthritis
Cancer
Dizziness/Fainting
Excessive Bruising
Hay Fever
Heart Disease
Hepatitis C
Kidney Disease
Multiple Sclerosis
Radiation Treatment
Rheumatoid Arthritis
Stomach Problems
Tuberculosis
Allergy - Latex
Allergy - Erythromicin
Artificial Joints
Cold Sores
Emphysema
Gastro-Intestinal
High Blood Pressure
Heart Murmur
HIV / AIDS
Low Blood Pressure
Nervous Disorders
Respiratory Problems
Sinus Problems
Stroke
Tumors
Last Name:
*
Health Card #:
*
New Patient Form
Have you ever had complications following dental treatment?
Yes
No
Last Name:
*
Acknowledgement:
To the best of my knowledge, all of the preceding information is true and correct. I have not knowingly withheld information and have had the opportunity to ask questions and receive answers regarding the medical profile. If I ever have a change in my health, I will inform the office at my next dental appointment.
Do you grind your teeth (either consciously or while sleeping)?
Yes
No
Have you ever been hospitalized within the last 5 years due to a surgery or illness?
Yes
No
Do you have any other health issues, allergies, conditions, or diseases not listed above that we should be aware of?
Yes
No
Email
Do your teeth experience sensitivity to cold or hot temperatures?
Yes
No
Gender
Male
Female
Medical & Dental History
If YES, please indicate here:
If yes, when are you expecting?
When was your last visit to the dentist
Work Phone
Do you grind your teeth (either consciously or while sleeping)?
Yes
No
Your Primary Care Physician's name:
If YES, please indicate here
*
If female, are you pregnant?
Yes
No
Mobile Phone
Do your gums bleed when you brush or floss?
Yes
No
Date and time
Prior Dentist's name:
Are any of your teeth currently causing you pain?
Yes
No
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Occupation:
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Do you use recreational drugs of any kind?
Yes
No
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