New Patient Form

Patient Information

Medical History

General Questions

Yes — No — If, yes please write


Pregnant/Trying to get pregnant?Nursing?Taking oral contraceptives?

AsprinPenicillinCodeineAcrylicMetalLatexSulfa DrugsLocal AnestheticsNo allergiesOther

Current Health


AIDS/HIV PositiveRadiation TreatmentDiabetesHepatitis ARecent Weight LossDrug AddictionHepatitis B or CRenal DialysisAnemiaRheumatic FeverEmphysemaHigh Blood PressureRheumatismArthritis/GoutEpilepsy or SeizuresHigh CholesterolScarlet FeverArtificial Heart ValveExcessive BleedingHives or RashArtificial JointExcessive ThirstHypoglycemiaSickle Cell AnemiaAsthmaFainting Spells/DizzinessIrregular HeartbeatSinus TroubleBlood DiseaseKidney ProblemsLeukemiaStomach/Intestinal DiseaseBreathing ProblemsFrequent HeadachesLiver DiseaseStrokeBruise EasilyLow Blood PressureSwelling of LimbsCancerThyroid DiseaseChemotherapyHay FeverMitral Valve ProlapseChest PainsHeart Attack/FailureOsteoporosisTuberculosisHeart MurmurPain in Jaw JointsTumors or GrowthsHeart PacemakerUlcersConvulsionsVenereal DiseaseAutoimmune DiseasesDepressionBleeding GumsHistory of OrthoCanker Sores