New Patient Form

Patient Information

Sex

Responsible Party Information

Questionnaire

Parents/Guardians: Please note the following questions pertain to the patient being seen within our office(s). Please answer all questions for your child.
Are you under a physician's care?
Are you taking any medications or substances?
Are you taking a blood thinner?
Are you allergic to any medication or substances?
Do you have any problems with penicillin, antibiotics, local anesthetics (Novocaine) or other allergies?
Are you sensitive to any metals or latex?
Are you pregnant or suspect you are?
Do you take birth control medications?
Have you ever been treated for heart disease?
Do you have a pacemaker or an artificial heart valve implant?
Have you ever had rheumatic fever?
Are you aware of having a heart murmur?
Do you have high blood pressure?
Have you ever had a serious illness, major surgery, or cancer?
Have you ever had radiation treatment, chemotherapy, or any other?
Do you have any soreness, clicking, or popping in your jaw joint?
Do you have any blood disorders such as anemia, leukemia, hemophilia, etc?
Do you have any artificial joints / prosthesis?
Have you ever bled excessively after being cut or injured?
Have you ever received a blood transfusion?
Do you have any kidney or liver problems?
Do you have any stomach problems?
Do you have a history of seizures or epilepsy?
Are you a diabetic?
Do you have asthma?
Do you have any of the following: ADD, ADHD, or Autism Spectrum Disorder?
Are you HIV positive?
Do you have AIDS?
Have you had or do you test positive for hepatitis?
Do you or have you had tuberculosis?
Do you smoke, chew, use snuff or any other forms of tobacco?
Do you consume alcoholic beverages?
Do you habitually use controlled substances?