New Patient Medical History Form Patient Name:* First Middle Last DOB:* MM slash DD slash YYYY Preferred Pronouns:* Preferred Name:* 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 If so, 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 Phone Number:*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]), the reason for taking and all dosages:*Do you require antibiotic premedication prior to your dental visits?* Yes No If so, please list the following:Name of antibiotic and dose:* Reason for premedication:* Name and phone of managing physician:* Do you have any of the following diseases or conditions?* ADD/ADHD Allergy - Aspirin Allergy - Codeine Allergy - Latex Allergy - Penicillin/Amoxicillin Allergy - Seasonal Allergy - Sulfa Allergy - Tree Nut Anemia Angina Anxiety Arthritis Artificial Joints Asthma Blood Disorder Blood Thinner Cancer Congestive Heart Failure Depression Diabetes Dizziness Eating Disorder Epilepsy Excessive Bleeding Fainting Gastrointestinal Disease Glaucoma Headaches/Migraines Head Injuries Heart Attack Heart Disease Heart Valve Conditions Hepatitis High Blood Pressure HIV or AIDS Jaundice Jaw Pain/Popping/Clicking 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 None 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:*Are you currently pregnant?* Yes No Is it high risk?* Yes No Due Date* MM slash DD slash YYYY Do you have an allergy or sensitivity to any pain medication, sedation medication or local anesthetic/epinephrine ? If so, please list:*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:* Aligning your teeth with braces or clear aligners Botox Comprehensive Care Dental Implants / Replacement of missing teeth Improving the appearance of your smile Sedation for Dental Visits Sleep Apnea Alternatives to CPAP Tooth Replacement (bridges, partial dentures, etc) Whitening Wisdom Teeth 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 CAPTCHAEmailThis field is for validation purposes and should be left unchanged. FollowFollowFollowFollow © Ann Arbor Smiles Dental Group 2020 | Sitemap | Site Map| Accessibility Statement
