New Patient Form

Good Fair Poor

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Aspirin Latex Codeine Penicillin Dental Anesthetics Terracycline Erythromycin Jewelry/Metals

Abnormal Bleeding Herpes/Fever Blisters Alcohol/Drug Abuse High Blood Pressure Anemia HIV /AIDS Arthritis Hospitalized (Any Reason) Artificial Bones, Joints or Valves Kidney Problems Asthma Liver Disease Blood Transfusion Low Blood Pressure Cancer/Chemotherapy Lupus Colitis Mitral Valve Prolapse Congenital Heart Defect Pacemaker Diabetes Psychiatric Problems Difficulty Breathing Radiation Treatment Emphysema Rheumatic/Scarlet Fever Epilepsy Seizures Fainting Spells Shingles Frequent Headaches Sickle Cell Disease Glaucoma Sinus Problems Hay Fever Stroke Heart Attack Thyroid Problems Heart Murmur Tuberculosis (TB) Heart Surgery Ulcers Hemophilia Venereal Disease Hepatitis

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Good Fair Poor

Yes No

Yes No

Hard Medium Soft

Sensitivity (hot, cold, or sweet) Headaches, earaches, or neck pain Teeth or fillings breaking Grinding or clenching teeth Bleeding, swollen, or irritated gums Loose, tipped, or shifting teeth Bad breath

Dentures Partial Dentures Periodontal (gum) treatments Orthodontic (braces) treatment

Make your teeth whiter Make your teeth straighter Close spaces between teeth Replace black metal fillings with tooth-colored restorations Repair chipped teeth Replace missing teeth Replace old crowns that don't match Have a smile makeover