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Ann Arbor Smiles Huron Parkway

Call us at 734-677-8700

2365 South Huron Parkway • Ann Arbor, MI 48104

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Ann Arbor Smiles West Stadium

Call us at 734-662-3222

1795 West Stadium • Ann Arbor, MI 48103

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New Patient Medical History Form

Patient Name:
First Middle Last Suffix
Email
DOB:
MM slash DD slash YYYY
In the event of any emergency who is the closest relative we can contact?
Emergency Contact Name
Relationship
Phone Number
Dental History
When was the last time you had your teeth cleaned?
MM slash DD slash YYYY
Do you experience Dental Anxiety?
- Yes
- No
Please describe. Is there any way we can make you more comfortable?
Are you aware of any dental problems?
- Yes
- No
If so, what?
Medical History
Do you have a primary care physician?
- Yes
- No
If so, whom?
When was your last visit?
MM slash DD slash YYYY
Have you had any problems in your general health in the past 5 years? Serious illness, hospitalization, surgery, etc…
- Yes
- No
If so, please describe
Please list all medications you are currently taking (including all prescriptions and OTC medications and supplements [i.e. medical marijuana, vitamins, etc]):
Do you require Pre-Medication prior to your dental visits?
- Yes
- No
If so, please describe
Do you have any of the following diseases or conditions?
- Allergy - Aspirin
- Allergy - Codeine
- Allergy - Latex
- Allergy - Other
- Allergy - Seasonal
- Allergy - Sulfa
- Allergy - Tree Nut
- Anemia
- Arthritis
- Artificial Joints
- Asthma
- Blood Disease
- Cancer
- Diabetes
- Dizziness
- Epilepsy
- Excessive Bleeding
- Fainting
- Glaucoma
- Head Injuries
- Heart Attack
- Heart Disease
- Heart Valve Conditions
- Hepatitis
- High Blood Pressure
- HIV or AIDS
- Jaundice
- Kidney Disease
- Liver Disease
- Low Blood Pressure
- Neck/Back Conditions
- Nervous System Conditions
- Osteoporosis
- Pacemaker
- Psychiatric Conditions
- Radiation Treatment
- Respiratory Conditions
- Sleep Apnea
- Sinus Conditions
- Stomach Conditions
- Stroke
- Thyroid Disorders
- Tuberculosis
- Tumors
- Ulcers
- Venereal Disease
If Yes, please check off the column.
Please describe conditions listed above in as much detail as possible:
Do you have any disease, condition, problem or allergies not listed above that you think the doctor should know about? If so, please describe:
Do you have an allergy or sensitivity to any antibiotics? If so, please list:
Are you currently pregnant?
- Yes
- No
Due Date
MM slash DD slash YYYY
Do you smoke, vape or use any tobacco products?
- Yes
- No
If so, what kind and how often?
Do you drink alcohol or use recreational drugs?
- Yes
- No
If so, what kind and how often?
Do you experience any jaw pain?
- Yes
- No
If so, please describe:
Do you snore?
- Yes
- No
If so, please describe:
Have you ever participated in a sleep study?
- Yes
- No
If so, please describe:
Are you interested in discussing any of the following:
- Botox or Dermal Filler
- Braces/Invisalign
- Dental Implants
- Sedation for Dental Visits
- Sleep Apnea Alternatives to CPAP
- Tooth Replacement (bridges, partial dentures, etc)
- Veneers/ Cosmetic Dentistry
- Wisdom Teeth
- Whitening
- Other:
Please describe
I acknowledge that I have reviewed ALL questions/alerts on this questionnaire and responded accordingly. There are no other medical conditions or medications/allergies that have not been listed. I am aware that I must notify the practice of any future changes.
Signature
Date
MM slash DD slash YYYY
Staff Initials:

Insurance Options

Smiles Dental Savings Plan
Care Credit

Delta Dental and Most Major Dental Insurances Are Accepted

Convenient Locations

Huron Parkway:
Tel: 734-677-8700
Text: 734-926-4506
2365 S Huron Pkwy
Ann Arbor, MI 48104
West Stadium:
Tel: 734-662-3222
Text: 734-821-5267
1795 West Stadium Blvd
Ann Arbor, MI 48103

Full Service Team

Emergency Dentistry
Cosmetic and Orthodontics
Sedation Dentistry
Prevention & Diagnostics
Restorative Dentistry
Sleep Medicine

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