New Patient Form Melissa Chavez-Grinde, DDS Cristina Chavez, DDS 1Step 12Step 2 General DentistryName* Patients Full Name Nickname If under 18 years old, name of parent or legal guardian: Date of BirthDay12345678910111213141516171819202122232425262728293031Month123456789101112Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Sex Male Female Please select one Married Single Minor Home Address Address Home PhoneCell PhoneEmail Who is Responsible for this account/Relationship to patient Occupation Employer Employer PhoneEmployer 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 PhoneWhom 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 DateMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 Confidential Health History1. Circle Appropriate Answer (Leave blank if you do not understand the question)Patient Same Date of BirthMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Is your general health good? Yes No If NO, explain Has there been a change in your health within the last year? Yes No If YES, explain Have you gone to the hospital or emergency room or had a serious illness in the last three years? Yes No If YES, explain Are you being treated by a physician now? Yes No If YES, explain Have you had problems with prior dental treatment? Yes No If YES, explain Date of lost dental exam Name of last treating denfist Are you in pain now? Yes No If YES, explain 2. Have You Ever Experienced Any Of The Following? (Please circle Yes or No for each)Chest pain (angina) Yes No Blood in stools Yes No Frequent vomiting Yes No Fainting spells Yes No Diarrhea or constipation Yes No Jaundice Yes No Recent significant weight loss Yes No Frequent urination Yes No Dry mouth Yes No Fever Yes No DiHiculty urinating Yes No Excessive thirst Yes No Night sweats Yes No Ringing in ears Yes No Difficulty swallowing Yes No Persistent cough Yes No Headaches Yes No Awollen Ankles Yes No Coughing up blood Yes No Dizziness Yes No Joint Pain or Stiffness Yes No Bleeding problems Yes No Blurred vision Yes No Shortness of breath Yes No Blood in urine Yes No Bruise easily Yes No Sinus problems Yes No Other 3. Have You Ever Had Or Do You Have Any Of The Following? (Please circle Yes or No for each)Heart disease Yes No Psychiatric care Yes No AIDS/HIV Yes No Family history of heart disease Yes No Surgeries Yes No Osteoporosis Yes No Heart attack Yes No Hospitalization Yes No Thyroid disease Yes No Artificial joint Yes No Diabetes Yes No Asthma Yes No Type/ Date of surgery Stomach problems or ulcers Yes No Family history of diabetes Yes No Hepatitis Yes No Heart defects Yes No Tumors or cancer Yes No Sexually transmitted disease Yes No Pacemaker Yes No Date implanted Heart murmurs Yes No Chemotherapy Yes No Herpes Yes No Rheumatic fever Yes No Radiation Yes No Canker or cold sores Yes No Skin disease Yes No Arthritis, rheumatism Yes No Anemia Yes No Hardening of arteries Yes No Emphysema or other lung disease Yes No Liver disease Yes No High blood pressure Yes No Kidney or bladder disease Yes No Eye disease Yes No Seizures Yes No Stroke Yes No Transplants Yes No Cosmetic surgery Yes No Eating disorders Yes No Tuberculosis Yes No 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 No Valium or sedatives Yes No Codeine or other opioids Yes No Penicillin or other antibiotics Yes No Latex Yes No Food Yes No Nitrous oxide Yes No Local anesthetic Yes No Metal Yes No 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 No Tobacco in any form Yes No Antibiotics Yes No Over-the-counter medicines Yes No Alcohol Yes No Supplements Yes No Weight loss medications Yes No Bisphosphonate (Fosamax) Yes No Aspirin Yes No Antidepressants Yes No Herbal supplements Yes No Opioids (e.g., Norco, Vicodin, Percocet, Percodan) Yes No 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 No If YES, how many months? Are you nursing? Yes No Are you taking birth control pills? Yes No 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 No If YES, please explain Have you ever been pre-medicated for dental treatment? Yes No If YES, please explain Have you tested positive for COVID-19? Yes No If YES, please explain Are you experiencing any ongoing or lasting symptoms or effects as a result? Yes No 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 No 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 No 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: DateMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Physician's Name: Physician's Name Phone NumberWhom would you like us to contact in case of an emergency?Name Name Relationship Phone NumberCommentsThis field is for validation purposes and should be left unchanged.