New Patient Form

Melissa Chavez-Grinde, DDS

Cristina Chavez, DDS

"*" indicates required fields

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General Dentistry

Name*

Patients Full Name Nickname

If under 18 years old, name of parent or legal guardian:

Date of Birth

Sex

Male

Female

Please select one

Married

Single

Minor

Home Address

Address

Home Phone

Cell Phone

Who is Responsible for this account/Relationship to patient

Occupation

Employer

Employer Phone

Employer Address

Name of Dental insurance Company

Group Number

If you are NOT the primary account holder, on your dental insurance plan:

Spouse/Parent name

Spouse/Parent Birthdate

Spouse/Parent Employed by

Occupation

Business Address

Street Address

Business Phone

Whom may we thank for referring you to our office?

It is the patients responsibility to inform the office of any changes in your insurance coverage.

A $50 cancelation fee will be charged for appointments canceled or broken within 24 hours of the scheduled appointment.

Patient or Guardians Signature

Date

Confidential Health History

1. Circle Appropriate Answer (Leave blank if you do not understand the question)

Patient Same

Date of Birth

Is your general health good?

Yes

If NO, explain

Has there been a change in your health within the last year?

Yes

If YES, explain

Have you gone to the hospital or emergency room or had a serious illness in the last three years?

Yes

If YES, explain

Are you being treated by a physician now?

Yes

If YES, explain

Have you had problems with prior dental treatment?

Yes

If YES, explain

Date of lost dental exam

Name of last treating denfist

Are you in pain now?

Yes

If YES, explain

2. Have You Ever Experienced Any Of The Following? (Please circle Yes or No for each)

Chest pain (angina)

Yes

Blood in stools

Yes

Frequent vomiting

Yes

Fainting spells

Yes

Diarrhea or constipation

Yes

Jaundice

Yes

Recent significant weight loss

Yes

Frequent urination

Yes

Dry mouth

Yes

Fever

Yes

DiHiculty urinating

Yes

Excessive thirst

Yes

Night sweats

Yes

Ringing in ears

Yes

Difficulty swallowing

Yes

Persistent cough

Yes

Headaches

Yes

Awollen Ankles

Yes

Coughing up blood

Yes

Dizziness

Yes

Joint Pain or Stiffness

Yes

Bleeding problems

Yes

Blurred vision

Yes

Shortness of breath

Yes

Blood in urine

Yes

Bruise easily

Yes

Sinus problems

Yes

Other

3. Have You Ever Had Or Do You Have Any Of The Following? (Please circle Yes or No for each)

Heart disease

Yes

Psychiatric care

Yes

AIDS/HIV

Yes

Family history of heart disease

Yes

Surgeries

Yes

Osteoporosis

Yes

Heart attack

Yes

Hospitalization

Yes

Thyroid disease

Yes

Artificial joint

Yes

Diabetes

Yes

Asthma

Yes

Type/ Date of surgery

Stomach problems or ulcers

Yes

Family history of diabetes

Yes

Hepatitis

Yes

Heart defects

Yes

Tumors or cancer

Yes

Sexually transmitted disease

Yes

Pacemaker

Yes

Date implanted

Heart murmurs

Yes

Chemotherapy

Yes

Herpes

Yes

Rheumatic fever

Yes

Radiation

Yes

Canker or cold sores

Yes

Skin disease

Yes

Arthritis, rheumatism

Yes

Anemia

Yes

Hardening of arteries

Yes

Emphysema or other lung disease

Yes

Liver disease

Yes

High blood pressure

Yes

Kidney or bladder disease

Yes

Eye disease

Yes

Seizures

Yes

Stroke

Yes

Transplants

Yes

Cosmetic surgery

Yes

Eating disorders

Yes

Tuberculosis

Yes

Other

4. Are You Allergic To Or Have You Had A Reaction To Any Of The Following? (Please Circle Yes Or No For Each)

Aspirin

Yes

Valium or sedatives

Yes

Codeine or other opioids

Yes

Penicillin or other antibiotics

Yes

Latex

Yes

Food

Yes

Nitrous oxide

Yes

Local anesthetic

Yes

Metal

Yes

Other

55. Are You Taking Or Have You Taken Any Of The Following In The Last Three Months? (Please Circle Yes Or No For Each)

Recreational drugs

Yes

Tobacco in any form

Yes

Antibiotics

Yes

Over-the-counter medicines

Yes

Alcohol

Yes

Supplements

Yes

Weight loss medications

Yes

Bisphosphonate (Fosamax)

Yes

Aspirin

Yes

Antidepressants

Yes

Herbal supplements

Yes

Opioids (e.g., Norco, Vicodin, Percocet, Percodan)

Yes

If YES, please explain reason:

Please list all prescription medications:

6. Women Only (Please Circle Yes Or No For Each)

Are you or could you be pregnant?

Yes

If YES, how many months?

Are you nursing?

Yes

Are you taking birth control pills?

Yes

7. All Patients (Please Circle Yes Or No For Each)

Do you have or have you had any other diseases or medical problems NOT listed on this form?

Yes

If YES, please explain

Have you ever been pre-medicated for dental treatment?

Yes

If YES, please explain

Have you tested positive for COVID-19?

Yes

If YES, please explain

Are you experiencing any ongoing or lasting symptoms or effects as a result?

Yes

If YES, what are these symptoms or effects?

Are you currently under the care of a physician or taking any medications for any of the conditions listed above?

Yes

If YES, please list

If patient answers "yes" to any of the questions above, consider seeking additional information from the patient regarding their symptoms and medications, prior to treatment.

Are there any issues or conditions that you would like to discuss with the dentist in private?

Yes

The practice of dentistry involves treating the whole person. If the dentist determines that there may be a potentially medically compromised situation, medical consultation may be needed prior to commencement of dental treatment.

I authorize the dentist to contact my physician.

Patient's Signature:

Date

Physician's Name:

Physician's Name

Phone Number

Whom would you like us to contact in case of an emergency?

Name

Relationship

Phone Number

Comments

This field is for validation purposes and should be left unchanged.