new patient form

Getting to know you

The more we know about you, the better we can serve your needs. Before your initial consultation, please take a few minutes to complete our New Patient Form below. Or if you prefer, you can print a PDF of the questionnaire and bring it to your visit.

PATIENT INFORMATION

First Name:

Last Name:

Email: *

Mailing Address:

City:

State:

Zip:

Phone - Home:

Phone - Mobile:

Employer:

Insurance Company:

Insurance ID/Group#:

Occupation:

Reason for today's visit:

MEDICAL HEALTH

Name of Physician:

Last complete physical:

Overall general health:

Do you want whiter teeth?: select...YesNo

Do you snore?: select...YesNo

Check all that apply:

Heart murmur or congenital heart defect

Heart surgery or heart disease

Rheumatic fever

Heart Pacemaker

Abnormal blood pressure HIGH / LOW

Bleeding problems

Diabetes

Kidney Disease

Jaundice or liver disease

Cancer

Hepatitis

HIV +

Herpes

Hemophillia

Need Premedication

Allergic or sensitive to Penicillin

Allergic or sensitive to Aspirin

Allergic or sensitive to Codeine

Allergic or sensitive to Demerol

Allergic or sensitive to Local anesthetics like Novocaine

Allergic or sensitive to Other drugs, medicines or foods

Are you currently taking any medications

Other medical problems not listed above:

Chemical dependency

Headaches

Recent weight loss

Convulsions or epilepsy

Dizziness or fainting spells

Stroke

Lung problems or Tuberculosis

Glaucoma

Ulcers

Arthritis

Joint Replacement

Blood Disease, ie. Anemia

Sinus Trouble

Females only: Are you pregnant?

Radiation treatment

Breathing Problems

Bisphosohonates

Currently under the care of a physician

DENTAL HEALTH

Previous dentist:

When was your last visit?:

Previous dental x-rays were taken:

Check all that apply:

Are your teeth sensitive to sweets?  Temperature? 

Do you notice popping in your jaw?

Do you clench or grind your teeth?

Do you wear a night guard?

Does food pack in between your teeth?

Do you have any loose teeth?

Does it hurt to bite down on any of your teeth?

Has anyone told you that you snore?

Do you think that you have sleep apnea?

Do your gums bleed?

Have you had any teeth removed?

Have you had braces?

Do you smoke or chew tobacco?

Do you floss?

Do you like your smile?

Do you want straighter teeth?

Do you use a CPAP?

Do you doze off easily?

Is there anything else that you would like to discuss with Dr. Harding that was not listed above?: