NEW PATIENT FORM

For your convenience we have made the new patient forms available online.

Thank you! Nick Levi, DDS and staff.

 

Health History

 

Name:
 
What is the reason for your visit today?
Are you satisfied with your teeth appearance?

 No

 Yes

Are you interested in Professional Whitening of your teeth? 

 No

 Yes

Are you interested in straightening of your teeth?

 No

 Yes

Are you interested in bad breath management techniques? 

 No

 Yes                                                                                                     

Date of:
Last Dental Visit
Last Dental Cleaning
Last Full Mouth X-Rays
What was done at your last dental visit?
How often do you have dental examinations?

Previous Dentist's Name

Telephone

Address

How often do you brush your teeth?
Do you use electric toothbrush? 

 No

 Yes

How often do you floss?
What other dental aids do you use (toothpick, etc.)?
Do you have any dental problems now?

 No

 Yes

If Yes, please describe
Do you feel nervous about having dental treatment? 

 No

 Yes

If yes, what is your biggest concern?
Have you ever had an upsetting dental experience?

 No

 Yes

If yes, please describe
Is there anything else about having dental treatment that you would like us to know? 
What are your hobbies or special interests (sports etc.)?

Are any of your teeth sensitive to:                                    Have you ever had:                                                            
Hot or cold?   No  Yes   Orthodontic treatment?  No  Yes
Sweets?   No  Yes   Oral Surgery?   No  Yes
Biting or chewing?   No  Yes   Periodontal (gum) treatment?  No  Yes

Have you noticed any

mouth odors or bad tastes?

  No  Yes   A bite plate or mouth guard?   No  Yes

Do you frequently get cold

sores, blisters or any other oral lesions?

  No  Yes  

A serious injury to the mouth or head?

  No  Yes
Do your gums bleed or hurt?  No  Yes   Have you experienced:

Have your parents experienced

gum disease or tooth loss?

  No  Yes  

Headaches, neckaches or shoulder aches?

  No  Yes

Have you noticed any loose teeth

or change in your bite?

  No  Yes  

Sore muscles (neck, shoulders, side of face)?

  No  Yes

Does food tend to become

caught in between your teeth?

  No  Yes   Pain (side of face, joint, ear)?  No  Yes
Do you:   Clicking or popping of the jaw?  No  Yes

Clench or grind teeth while

awake or asleep?

  No  Yes  

Difficulty in chewing on either side of the mouth?

  No  Yes
Bite your lips or cheeks regularly?  No  Yes  

Difficulty in opening or closing the

mouth?		  No  Yes
Mouth breathe while awake or asleep?   No  Yes  

Do you have tired jaws especially in the morning?

  No  Yes

 

Date of last health care exam:           

What was this exam for?
Have you been hospitalized in the last 5 years?

 No

 Yes

If yes, reason:
Are you currently receiving care?

 No

 Yes

If yes, nature of care:
Please list all the names and phone numbers of the physicians who are currently providing you care:
1.
2. 
3.

For the following questions circle yes or no. Your answers are for our records only and will be confidential. Please note that during your initial visit you will be asked some questions about your response. Our team may ask additional questions concerning your health.

Heart (Surgery, Disease, Attack)  No  Yes   Heart Murmur  No  Yes
Latex Sensitivity  No  Yes   Anemia  No  Yes
Diabetes  No  Yes   Previous Biopsies  No  Yes
Epilepsy  No  Yes   Slow-Healing Mouth Sores  No  Yes

Hepatitis, Any Form (specify)

  No  Yes  

Other Infections (specify)

                 

 No  Yes
Rheumatic Fever  No  Yes   Recurrent Illnesses  No  Yes
Asthma  No  Yes   Psychosis  No  Yes
HIV Positive or AIDS Related Complex  No  Yes   Liver Disease (including Jaundice)  No  Yes
Mitral valve prolapse  No  Yes   Unintentional Weight Loss/Gain  No  Yes
Abnormal Heart Condition  No  Yes   Glaucoma  No  Yes
Kidney Disease  No  Yes   Abnormal Bleeding from a cut  No  Yes
Joint Replacement  No  Yes   Sore/Enlarged Lymph Nodes  No  Yes
Venereal Disease  No  Yes   Emphysema or other Respiratory Illnesses  No  Yes

 

For Women:
Are you pregnant?                       
If no, are you planning a pregnancy in the near future? 

 No

 Yes

Are you a nursing mother?

 No

 Yes

Are you taking birth control pills? 

 No

 Yes

 

Are you required to Pre-Medicate before dental treatment?

 No

 Yes                                                                                                       

Abnormal Blood Pressure?

 No

 Yes 

If yes, what is it usually:  S / D

Are you allergic or have you had a reaction to:

a. Local anesthetics

 No

 Yes

b. Penicillin or other antibiotics

 No

 Yes

c. Aspirin

 No

 Yes

d. Codeine, valium or other sedatives

 No

 Yes

e. Other
Do you smoke / chew tobacco? 

 No

 Yes

If so, how much do you smoke per day? 

Please list any medications you are currently taking:

1.

2.
3.
4. 
5. 
6.
Are you taking Tagamet (Cimetidine)? 

 No

 Yes

If yes, how often? 
Do you take Antacids? 

 No

 Yes

If yes, how often? 
Are you taking any herbal supplements?

 No

 Yes

If yes, which ones?
Diet:
Restricted Diet 
How many meals a day?
Food Allergies 
Sugar in your diet: 

 None       Slight      Moderate      High    

Do you have or have you had any disease, condition or problem not listed? 

 No

 Yes

If yes, please list 

 

I understand the above information is necessary to provide me with dental care in a safe and efficient manner. I have answered all questions to the best of my knowledge. Should further information be needed, you have my permission to ask the respective health care provider or agency, who may release such information to you. I will notify the doctor of change in my health and medication.