(321) 783-7411

Cocoa Beach Dentistry New Patient Form

New Patients: Please fill out our New Patient Health History online form.
Please E-Sign the form when asked before submitting.
Thank you!

American Dental Association logo

American Dental Association

America's leading advocate for oral health

    Note: *Required field

    As required by law, our office adheres to written policies and procedures to protect the privacy of information about you that we create, receive or maintain. Your answers are for our records only and will be kept confidential subject to applicable laws. Please note that you will be asked some questions about your responses to this questionnaire and there may be additional questions concerning your health. This information is vital to allow us to provide appropriate care for you. This office does not use this information to discriminate.

    If you are filling out this form for another person, what is your relationship to that person?

    Do you have any of the following diseases or problems?

    (Check OK if you don't know the answer to the the question)

    Yes No OK

    Yes No OK

    Active Tuberculosis*

    Cough that produces blood*

    Persistent cough greater than a 3 week duration*

    Been exposed to anyone with tuberculosis*

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    DENTAL INFORMATION

    Yes No OK

    Yes No OK

    Do your gums bleed when you brush or floss?*

    Have you ever had orthodontic (braces) treatment?*

    Are your teeth sensitive to cold. hot. sweets or pressure?*

    Do you have any clicking, popping or discomfort in your jaw?*

    Is your mouth dry?*

    Do you grind your teeth?*

    Have you had any periodontal (gum) treatments?*

    Do you have sores or ulcers in your mouth?*

    Do you have earaches or neck pains?*

    Do you wear dentures or partials?*

    Have you had any problems associated with previous dental treatment?*

    Do you participate rn active recreational activities?*

    Are you currently experiencing dental pain or discomfort?*

    Have you ever had a serious inJury to your head or mouth?*

    Do you drink bottled or filtered water?*

    Is your home water supply fluoridated?*

    If yes, how often?*

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    MEDICAL INFORMATION

    Yes No OK

    Yes No OK

    Are you now under the care of a physician?*

    Have you had a serious illness, operation or been hospitalized in the past 5 years?*

    Are you taking or have you recently taken any prescription or over the counter medicine(s)?*

    Are you in good health?*

    Has there been any change in your general health within the past year?*

    Do you wear contact lenses?*

    Do you use controlled substances?*

    Joint Replacement. Have you had an orthopedic total joint (hip, knee, elbow, finger) replacement?*

    Do you use tobacco (smoking, snuff, chew, bidis)?*

    If so, how interested are you in stopping?

    Are you taking or scheduled to begin taking an antiresorptive agent (hke Fosamax, Actonel, Atelvia, Boniva, Reclast, Prolia) for osteoporosis or Paget's disease?*

    Do you drink alcoholic beverages?*

    Since 2001, were you treated or are you presently scheduled to begin treatment with an ant1resorpt1ve agent (like Aredia, Zometa, XGEVA) for bone pain, hypercalcemia or skeletal complications resulting from Paget's disease, multiple myeloma or metastatic cancer?*

    WOMEN ONLY Are you:

    Yes No N/A

    Pregnant?*

    Taking birth control pills or hormonal replacement?*

    Nursing?*

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    MEDICAL INFORMATION Cont...

    Allergies • Are you allergic to or have you had a reaction to:

    Yes No OK

    Yes No OK

    Local anesthetics?*

    Latex (rubber)?*

    Asprin?*

    Iodine?*

    Penicillin or other antibiotics?*

    Hay fever/seasonal?*

    Barbiturates. sedatives. or sleeping pills?*

    Animals?*

    Sulfa drugs*

    Food?*

    Codeine or other narcotics?*

    Metals?*

    Other*

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    MEDICAL INFORMATION Cont...

    Please check below to indicate if you have or have not had any of the following diseases or problems.

    Yes No OK

    Congenital heart disease (CHD)

    Yes No OK

    Artificial (prosthetic) heart valve?*

    Unrepaired cyanotic CHD?*

    Previous infective endocarditis?*

    Repaired (completely) 1n last 6 months?*

    Damaged valves in a transplanted heart?*

    Repaired CHD with residual defects?*

    Except for the conditions listed above, antibiotic prophylaxis is no longer recommended for any other Form of CHD

    Cardiovascular disease*

    Mitral valve prolapse*

    Angina*

    Pacemaker*

    Arteriosclerosis*

    Rheumatic fever*

    Congestive heart failure*

    Rheumatic heart disease*

    Damaged heart valves*

    Abnormal bleeding*

    Heart attack*

    Anemia*

    Heart murmur*

    Blood transfusion*

    Low blood pressure*

    Hemophilia*

    High blood pressure*

    AIDS or HIV infection*

    Arthritis*

    Other congenital heart defects*

    Autoimmune disease*

    Rheumatoid arthritis*

    Glaucoma*

    Epilepsy*

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    MEDICAL INFORMATION Cont...

    Please check below to indicate if you have or have not had any of the following diseases or problems.

    Yes No OK

    Yes No OK

    Systemic lupus erythematosus*

    Hepatitis, Jaundice or liver disease*

    Asthma*

    Fainting spells or seizures*

    Bronchitis*

    Neurological disorders*

    Emphysema*

    Sleep disorder*

    Sinus trouble*

    Do you snore?*

    Tuberculosis*

    Mental health disorders*

    Stroke*

    Recurrent Infections*

    Chest pain upon exertion*

    Kidney problems*

    Chronic pain*

    Diabetes Type I or II*

    Night sweats*

    Eating disorder*

    Osteoporosis*

    Malnutrition*

    Persistent swollen glands in neck*

    Gastrointestinal disease*

    Severe headaches/migraines*

    G.E. Reflux/persistent heartburn*

    Severe or rapid weight loss*

    Ulcers*

    Sexually transmitted disease*

    Thyroid problems*

    Cancer / Chemotherapy / Radiation Treatment*

    Excessive urination*

    Has a physician or previous dentist recommended that you take antibiotics prior to your dental treatment?*

    Do you have any disease. condition, or problem not listed above that you think I should know about?*

    NOTE: Both doctor and patient are encouraged to discuss any and all relevant patient health Issues prior to treatment.

    I certify that I have read and understand the above and that the information given on this form is accurate. I understand the importance of a truthful health history and that my dentist and his/her staff will rely on this information for treating me. I acknowledge that my questions, if any, about inquiries set forth above have been answered to my satisfaction. I will not hold my dentist, or any other member of his/her staff, responsible for any action they take or do not take because of errors or omissions that I may have made in the completion of this form.

    Please sign the form below. Thank you!
    Required*

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    ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

    Purpose: This form is used to obtain acknowledgement of receipt of our Notice of Privacy Practices or to document our good faith effort to obtain that acknowledgement.

    I have received a copy of this office's Notice of Privacy Practices

    Please sign the form below. Thank you!
    Required*

    AUTHORIZATION TO RELEASE INFORMATION

    Purpose: This form is used to obtain authorization to release information regarding you covered under the Privacy Act to people other than yourself. I authorize the following persons(s) to have access to information covered under the Privacy Practice regarding myself.

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