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 NumberDental 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 describePlease 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 describeDo 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. SignatureDate MM slash DD slash YYYY Staff Initials: CAPTCHAPhoneThis field is for validation purposes and should be left unchanged. FollowFollowFollowFollow © Ann Arbor Smiles Dental Group 2020 | Sitemap | Site Map| Accessibility Statement
