New Patient Form New Patient Form New Patient FormAs 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.Today's Date MM slash DD slash YYYY First Name* Last Name* Email Home PhoneCell/Work PhoneAddress Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Occupation Social Security Number Date of Birth MM slash DD slash YYYY AgeHeight Weight Emergency Contact Name Emergency Contact Phone NumberEmergency Contact Relationship Pharmacy Name Pharmacy Phone NumberIf you are completing this form for another person, what is your relationship to that person?Medical HistoryDo you have any of the following diseases or medical conditions? Please check "I don't know" if you don't know the answer to the question.Active Tuberculosis* Yes No I don't know Persistant cough greater than 3 week duration* Yes No I don't know Cough that produces blood* Yes No I don't know Been exposed to anyone with tuberculosis* Yes No I don't know Are you now under the care of a physician? Yes No I don't know If yes, Physician's Name* Physician's Phone NumberPhysician's Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Are you in good health? Yes No I don't know Has there been any change in your general health within the past year? Yes No I don't know If yes, what condition(s) is/are being treated?Date of last physical exam: MM slash DD slash YYYY Have you had a serious illness, operation, or been hospitalized in the past 5 years? Yes No I don't know If yes, what was the illness or problem?Are you taking or have you recently taken any prescription or over the counter medicine(s)? Yes No I don't know If so, please list all, including vitamins, natural or herbal supplements, and/or dietary supplements below.Have you had an orthopedic total joint (hip, knee, elbow, finger) replacement? Yes No I don't know If yes, date:* MM slash DD slash YYYY If yes, have you had any complications?Have you or are you currently taking any antiresorptive (bisphosphonates) medications for osteoporosis, osteopenia or bone cancer such as Fosamax (Alendronate), Actonel (Risendronate), Boniva (Ibandronate), or Reclast (Zolendronic Acid)? Yes No I don't know If yes, please provide more details: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? Yes No I don't know If yes, date treatment began: MM slash DD slash YYYY Do you use controlled substances (drugs)? Yes No I don't know Do you use tobacco (smoking, snuff, chew, bidis, vape)? Yes No I don't know If yes, how interested are you in stopping/quitting? Very Somewhat Not interested WOMEN ONLYAre you:Pregnant? Yes No I don't know If yes, number of weeks:* Taking birth control pills or hormonal replacement? Yes No I don't know Nursing? Yes No I don't know AllergiesAre you allergic to or have you had a reaction to:Local anesthetics* Yes No I don't know If yes, specify type of reaction:*Aspirin* Yes No I don't know If yes, specify type of reaction:*Penicillin or other antibiotics* Yes No I don't know If yes, specify type of reaction:*Barbiturates, sedatives, or sleeping pills* Yes No I don't know If yes, specify type of reaction:*Sulfa drugs* Yes No I don't know If yes, specify type of reaction:*Codeine or other narcotics* Yes No I don't know If yes, specify type of reaction:*Metals* Yes No I don't know If yes, specify type of reaction:*Latex (Rubber)* Yes No I don't know If yes, specify type of reaction:*Iodine* Yes No I don't know If yes, specify type of reaction:*Hay fever/seasonal* Yes No I don't know If yes, specify type of reaction:*Food* Yes No I don't know If yes, specify type of reaction:*Animals* Yes No I don't know If yes, specify type of reaction:*Other* Yes No I don't know If yes, specify type of reaction:*Please indicate if you have or have not had any of the following diseases or problems:Artificial (prosthetic) heart valve Yes No I don't know Previous infective endocarditis Yes No I don't know Damaged valves in transplanted heart Yes No I don't know Congenital heart disease (CHD) Yes No I don't know Unrepaired, cyanotic CHD Yes No I don't know Repaired (completely) in last 6 months Yes No I don't know Repaired CHD with residual defects Yes No I don't know Except for the conditions listed above, antibiotic prophylaxis is no longer recommended for any other form of CHD.Cardiovascular disease Yes No I don't know Angina Yes No I don't know Arteriosclerosis Yes No I don't know Congestive heart failure Yes No I don't know Damaged heart valves Yes No I don't know Heart attack Yes No I don't know Heart mumur Yes No I don't know Low blood pressure Yes No I don't know High blood pressure Yes No I don't know Other congenital heart defects Yes No I don't know Mitral valve prolapse Yes No I don't know Pacemaker Yes No I don't know Rheumatic fever Yes No I don't know Rheumatic heart disease Yes No I don't know Abnormal bleeding Yes No I don't know Anemia Yes No I don't know Blood transfusion Yes No I don't know If yes, date:* MM slash DD slash YYYY Hemophilia Yes No I don't know AIDS/HIV Infection Yes No I don't know Arthritis Yes No I don't know Autoimmune disease Yes No I don't know Rheumatoid arthritis Yes No I don't know Systemic lupus erythematosus Yes No I don't know Asthma Yes No I don't know Bronchitis Yes No I don't know Emphysema Yes No I don't know Sinus trouble Yes No I don't know Tuberculosis Yes No I don't know Cancer/Chemotherapy/Radiation Treatment Yes No I don't know Chest pain upon exertion Yes No I don't know Chronic pain Yes No I don't know Diabetes Type I or II Yes No I don't know Eating disorder Yes No I don't know Malnutrition Yes No I don't know Gastrointestinal disease Yes No I don't know G.E. Reflux/persistent heartburn Yes No I don't know Ulcers Yes No I don't know Thyroid problems Yes No I don't know Stroke Yes No I don't know Glaucoma Yes No I don't know Hepatitis, jaundice or liver disease Yes No I don't know Epilepsy Yes No I don't know Fainting spells or seizures Yes No I don't know Neurological disorders Yes No I don't know If yes, specify:* Sleep disorder Yes No I don't know Do you snore? Yes No I don't know Mental health disorders Yes No I don't know If yes, specify:* Recurrent Infections Yes No I don't know Type of infection: Kidney problems Yes No I don't know Osteoporosis Yes No I don't know Severe headaches/migraines Yes No I don't know Severe or rapid weight loss Yes No I don't know Sexually transmitted disease Yes No I don't know Has a physician or previous dentist recommended that you take antibiotics prior to your dental treatment? Yes No I don't know Name of physician making recommendation: Physician PhoneDo you have any disease, condition, or problem not listed above that you think we should know about? Yes No I don't know If yes, please explain:*Dental HistoryDo your gums bleed when you brush or floss? Yes No Sometimes I don't know Are your teeth sensitive to cold, heat, sweets, or pressure? Yes No Sometimes I don't know Is your mouth dry? Yes No Sometimes I don't know Have you had any periodontal (gum) treatments? Yes No I don't know Have you ever had orthodontic (braces) treatment? Yes No I don't know Have you had any problems associated with previous dental treatment? Yes No I don't know Are you currently experiencing dental pain or discomfort? Yes No I don't know Do you have earaches or neck pains? Yes No I don't know Do you have any clicking, popping or discomfort in the jaw? Yes No I don't know Do you brux or grind your teeth? Yes No I don't know Do you have sores or ulcers in your mouth? Yes No I don't know Do you wear dentures or partials? Yes No I don't know Have you ever had a serious injury to your head or mouth? Yes No I don't know Date of your last dental exam: MM slash DD slash YYYY What was done at that time?Date of your last dental x-rays: MM slash DD slash YYYY What is the reason for your dental visit today?How do you feel about your smile?I request and authorize Fairmount Dental to provide general dental treatments for me.I further request and authorize the taking of dental x-rays, the use of such anesthetics that may be considered necessary and/or advisable to diagnose and/or treat my/the dental patient's conditions, and provide treatments as deemed necessary and/or advisable by the doctor responsible for my/the dental patient's treatment. The usual and most frequent risks for complications occurring from dental treatment include, but are not limited to, the possibility of pain or discomfort during and following treatment, swelling, infection, bleeding, sensitivity, injury to adjacent teeth and surrounding tissues, reactions to injections (local anesthesia) such as numbness and tingling sensation in the lip, tongue, chin, gums, cheeks, and teeth (which is usually transient but on occasion, may be permanent), and allergic reactions to anesthetics and other dental materials, changes in occlusion (biting), development of a transient or permanent temporomandibular joint (TMJ) problem (including, but not limited to muscle cramps or spasms, referred pain to ear, neck, or head); delayed healing and treatment failure. The risks of complications from medications used/prescribed include, but are not limited to, drowsiness, lack of awareness and coordination, nausea, vomiting, allergic reactions, etc. Some medications may be influenced by the use of alcohol, tranquilizers, sedatives or other drugs. It is not advisable to operate any motor vehicle or hazardous device while experiencing side effects of any medications we may prescribe. It is important to know that antibiotics decrease the effectiveness of oral contraceptives, so it is advised that other/additional contraceptive measures be taken during the administration of antibiotics. I understand that during the course of my/the patient's dental treatment something unexpected may arise that may necessitate procedures in addition to or different from those planned. I am aware that the practice of dentistry is not an exact science, and I acknowledge that no guarantees have been made concerning the results of the treatment that I/the patient will receive. All of my questions have been answered to my satisfaction. I understand that I may revoke this consent to treatment at any time and that no further action based on this consent will be initiated except to the extent of treatment and procedures have already been performed or initiated. I confirm that I have read this form or it was read to me, and that all inapplicable paragraphs, if any, were crossed out before I signed below.I have received a copy of the Notice of Privacy Practices. YesNote: both doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment.* I certify that I have read and understand the above and that the information given on this form is accurate. I understand the importance of a truthful health history and that my dentist and his/her staff will rely on this information for treating me. I acknowledge that my questions, if any, about inquiries set forth above have been answered to my satisfaction. I will not hold my dentist, or any other member of his/her staff responsible for any action they take or do not take because of errors or omissions that I may have made in the completion of this form.Signature of Patient/Legal Guardian*Print Name* If other than patient, indicate relationship: Witness SignatureDate* MM slash DD slash YYYY CAPTCHA
