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New Patient Dental and Medical History
Thank you for choosing Gatlin Creek Dentistry for your dental needs! Please complete and submit the following form for your patient records.
39
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HIPAA
Compliance
1
Patient Name
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First Name
Last Name
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2
Email
example@example.com
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3
Phone Number
Area Code
Phone Number
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4
Patient's Date of Birth
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Date
Month
Day
Year
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5
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Afghanistan
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American Samoa
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The Bahamas
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Bolivia
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Botswana
Brazil
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Bulgaria
Burkina Faso
Burundi
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Canada
Cape Verde
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Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
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Germany
Ghana
Gibraltar
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Guam
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Jordan
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North Korea
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Kosovo
Kuwait
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Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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6
If you are signing this form on behalf of the patient, please type in your name.
First Name
Last Name
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7
Your Relationship to Patient:
If you are signing this form on behalf of the patient. Example: parent, guardian
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8
How did you hear about us?
ex. google, drive-by, referral
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9
Referred by:
First Name
Last Name
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10
Emergency Contact
*
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11
Date of Last Dental Visit:
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12
Date of Last Complete Dental Exam:
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13
Reason for Your Upcoming Visit:
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14
Name of Previous Dentist:
Please list dentist's name or practice name.
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15
Location of Previous Dentist:
Please list city and state.
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16
Do you have teeth sensitivities?
Please check all that apply.
Hot
Cold
Sweets
Pressure
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17
Are you nervous about dental treatment?
YES
NO
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18
Do you have trouble getting numb?
YES
NO
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19
Are you happy with your smile?
YES
NO
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20
Have you ever been treated for gum disease?
YES
NO
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21
Do you clench or grind your teeth?
YES
NO
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22
Do you snore or does your spouse witness you snoring?
YES
NO
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23
Have you ever or are you currently taking or scheduled to take any of the following medications for osteoporosis or Paget's disease?
Please check all that apply.
Alendronate (Fosamax®)
Risedronate (Actonel®)
Ibandronate (Boniva®)
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24
Since 2001, were you treated or are you presently scheduled to begin treatment with the intravenous bisphosphonates (Aredia® or Zometa®) for bone pain, hypercalcemia or skeletal complications resulting from Paget's disease, multiple myeloma, metastatic cancer or osteoporosis?
YES
NO
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25
If yes, which one?
Check all that apply.
Aredia®
Zometa®
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26
If yes, please list date treatment began or will begin:
mm/dd/yyyy
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27
Are you currently under a physician's care?
YES
NO
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28
If yes, what for?
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29
Have you been hospitalized or had a serious illness in the last 3 years?
YES
NO
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30
Date of Last Medical Exam:
mm/dd/yyyy or mm/yyyy
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31
Do you use controlled substances?
YES
NO
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32
Do you have a history of Infective Endocarditis?
YES
NO
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33
Do you have a history of using chewing tobacco?
YES
NO
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34
Do you have or have you had...
Please check all that apply.
Chest Pain
Angina
Artificial Heart Valve
Pacemaker
Shortness of Breath
Emphysema/COPD
High Blood Pressure
Asthma
Frequent Cough
Sinus Problems
Hay Fever
Dizziness
Low Blood Pressure
Fainting Spells
Frequent Headaches
Seizures
Psychiatric Care
Bleeding Problems/Bruise Easily
Hemophilia
Anemia
Blood Transfusion
Dry Mouth
Heart Murmurs
AIDS/HIV Positive
Stroke
Heart Attack
Diabetes
Cancer
Chemotheraphy
Tumors or Growths
Radiation Treatment
Herpes
Ulcers
Artificial Joint
Alzheimer's Disease
Dementia
Anaphylaxis
Arthritis/Gout
Cold Sores
Convulsions
Cortisone Medicine
Drug Addiction
Stomach/Intestinal Disease
Frequent Diarrhea
Glaucoma
Hypoclycemia
Osteoporosis
Parathyroid Disease
Recent Weight Loss
Kidney Problems
Renal Dialysis
Liver Disease
Hepatitis A
Hepatitis B/C
Scarlet Fever
Shingles
Sickle Cell Disease
Tonsillitis
Thyroid Disease
Tuberculosis
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35
Please list any other medical conditions you have or have had, not listed above:
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36
Are you allergic to any of the following:
Acetaminophen
Aspirin
Codeine
Erythromycin
Ibuprofen
Latex
Metals
Penicillin
Sulfa
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37
Please list any other allergies you have, not listed above:
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38
Medications - please list medications you are currently taking or provide front office with list to scan:
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39
Signature
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