3698 S BRISTOL STREET | SANTA ANA | CA 92704

New Patient Information
(Form 2 of 2)

Medical History

Your Name (Last, First, Middle)

Physician's Name

Address

Phone

Date of Last Visit

Have you had any serious illnesses or operations?

Yes

If yes, please describe:

Have you ever had a blood transfusion?

Yes

If yes, give approximate date(s):

Do you or have you ever taken bisphosphonate medications for osteoperosis, cancer, or multiple myeloma (such as Fosamax, Actonel, Boniva, Reclast, Aredia, or Zometa)?

Yes

Are you currently under physician care?

Yes

If yes, please describe:

Are you pregnant or do you think you may be?

Yes

Are you nursing?

Yes

Are you taking birth control?

Yes

If yes, please describe:

Select yes if you have or have had the following:

AIDS/HIV positive

Yes

Anaphylaxis

Yes

Anemia

Yes

Arthritis

Yes

Artificial heart valves

Yes

Artficial joints

Yes

Asthma

Yes

Atopic (allegy prone)

Yes

Back problems

Yes

Blood disease

Yes

Cancer

Yes

Chemical dependency

Yes

Chemotherapy

Yes

Circulatory problems

Yes

Cortisone treatments

Yes

Cough (peristent)

Yes

Coughing up blood

Yes

Diabetes

Yes

Epilepsy

Yes

Fainting

Yes

Food allergies

Yes

Glaucoma

Yes

Headaches

Yes

Heart murmur

Yes

Heart problems

Yes

Hemophilia/abnormal bleeding

Yes

Herpes

Yes

High blood pressure

Yes

Jaw pain

Yes

Kidney disease or malfunction

Yes

Liver disease

Yes

Material allergies (latex, wool, metal, chemicals)

Yes

Mitral valve prolapse

Yes

Nervous problems

Yes

Pacemaker / heart surgery

Yes

Psychiatric care

Yes

Rapid weight gain or loss

Yes

Radiation treatment

Yes

Repiratory disease

Yes

Rheumatic fever

Yes

Scarlet fever

Yes

Shingles

Yes

Shortness of breath

Yes

Skin rash

Yes

Spina bifida

Yes

Stroke

Yes

Surgical implant

Yes

Swelling of feet or ankles

Yes

Thyroid disease or malfunction

Yes

Tobacco habit

Yes

Tonsilitis

Yes

Tuberculosis

Yes

Ulcer/colitis

Yes

Venereal disease

Yes

Hepatitis

Yes

If other, please specify:

List any medications you are currently taking, if any:

Authorization

I have reviewed the information on this questionnaire and it is accurate to the best of my knowledge. I understand that this information will be used by the dentist to help determine appropriate and healthful dental treatment. If there is any change in my medical status, I will inform the dentist.

Authorization Signature

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Date

(Form 2 of 2)

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New Patient Information (Form 2 of 2)​​

Medical History

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New Patient Information
(Form 2 of 2)