New Patient Health Form

Thank you for visiting our office. We want your visit to be pleasant and comfortable. Please help us by completing this form.

All of this information is completely confidential.

* Required

New Patient Health Form

Patient Information

MM slash DD slash YYYY

Medical History

Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions.
Are you under a physician's care now?
Have you ever had a serious head or neck injury?(Required)
Do you take, or have you taken, Phen-Fen or Redux?(Required)
Have you ever taken Fosamax, Boniva, Actonel, or any other medications containing bisphosphonates?(Required)
Are you on a special diet?(Required)
Do you use tobacco?(Required)
Do you use controlled substances?(Required)
Women: Are you pregnant/trying to get pregnant?
Are you taking oral contraceptives?(Required)
Are you nursing?(Required)
Are you allergic to any of the following?
Please check the box if you have ever had any of the following:
Have you ever had an serious illness not listed above?(Required)
I Agree