blivaissdds - New Patient Form

Patient Contact Information

The following information is requested to assist the Doctor in administering the proper dental service.
Please answer the questions to the best of your ability.

Thank you for your cooperation.

Date

Patient Number

Name

LastFirstMiddle

Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Home Phone

Area CodePhone Number

Work Phone

Area CodePhone Number

Cell Phone

Area CodePhone Number

Email address

Best way to contact you (please mark)

Home PhoneCell PhoneWork PhoneEmail

If Cell phone

CallText

Preferred way to confirm appointment

Home PhoneCell PhoneWork PhoneEmail

If cell Phone

CallText

Date of Birth

Social Security Number

Sex

MaleFemale

Height

Weight

Marital Status

SingleMarriedWidowedDivorced

Spouse's Name

Emergency Contact Information

Name

Address

Contact Number

Reason for your visit

Referred By

Occupation

Employer

Work Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Work (Phone)

Area CodePhone Number

Dental Insurance

YesNo

Insurance company

Insurance phone number

Area CodePhone Number

Member ID#

Group #

MEDICAL HISTORY

General heath (Please mark)

ExcellentGoodFairPoor

Last complete physical

Name of physician

Address of physician

Are you presently under the care of a physician?

YesNo

If so. for what reason?

Are you taking any medication now?

YesNo

If Yes, please list all Medications

Are you allergic to :

If any other Medications please list

Have you ever been hospitalized? If so give name of hospital, reason and dates.

	Yes	No
Have you had any radiological diagnostic x-rays in the last five years?
Have you had any blood transfusions?
Are you currently trying to modify your weight?
Do you take any medications to help in weight reduction?
Do you consume alcohol on a daily basis?
Have you experienced any recent weight change?

Do you smoke cigarettes?

YesNo

How many per day?

Is your blood pressure :

NormalLowHigh

WOMEN

Are you pregnant?

YesNo

How long?

Do you experience premenstrual syndrome?

YesNo

Do you have or have you ever been informed that you had any of the following :

	Yes	No
Chest Pains
Heart Disease
Rheumatic Fever
Congenital Heart Defects
Heart Murmur
Postural Hypotension (fainting spells)
Hypertension
Kidney Problems
Stroke
Thyroid Problems
Hormonal Problems
Ulcers
Tuberculosis or Lung Disease
Diabetes
Epilepsy or Seizures
Anemia
Cancer or Leukemia
Psychiatric Problems
Sickle Cell Disease
Glaucoma
Prosthetic Valves or Joints

	Yes	No
Bruise Easily
Jaundice
Asthma or Hay Fever
Allergies or Hives
Sinus Trouble
Arthritis
Excessive Urination and/or Thirst
Persistent Cough
Prolonged Bleeding Problems
Sexually transmitted diseases: (Gonorrhea. Syphilis. Genital Herpes
Genetic Problems
Skin Disease
AIDS
Unexplained Fevers
Prolonged Sore Throat
Enlarged Lymph Nodes
Night Sweats
Persistent Diarrhea
Bluish-Reddish Lesions
Fatigue
Covid 19

	Yes	No
Have you ever been tested for Hepatitis?
Do you have a history of cold sores. fever blisters, or canker sores?
Are you being treated with immunosuppressive drugs?
Have you ever used drugs for recreational purposes?

	Yes	No
Do you experience dry mouth (Xerostomia) ?
Do your gums feel tender or swollen?
Do your gums bleed while brushing and/or flossing?
Do you avoid brushing any part of your mouth because of pain or sensitivity?
Do you feel twinges of pain when your teeth come in contact with hot, cold, sweet or sour?
Are any of your teeth sensitive to air or during chewing?
Do you chew on only one side of your mouth?
Does food catch between your teeth'?
Do you feel your teeth are affecting your health in any way?
Have you ever had professional advice in dental home care?
Do you clench or grind your teeth while sleeping or during the day?
Do your facial muscles ever feel tired?
Do you have retention problems with your full or partial dentures?
Do you gag easily?

Patient Contact Information

Emergency Contact Information

MEDICAL HISTORY

WOMEN

Do you have or have you ever been informed that you had any of the following :

DENTAL HEALTH

CONSENT: