Medical History Form

Please make certain to fill out all five forms before you come for your first visit so that we can spend your entire first visit diagnosing your dental condition and mutually establish the trusting, caring relationship we value having with all our patients.

  1. Medical History Form
  2. Patient Account Information
  3. Corah's Dental Anxiety Scale
  4. Mount Sinai Dental Fear Inventory
  5. No Show & Cancellation Policy

Name *
Name
Address
Address
Home Phone
Home Phone
Work Phone
Work Phone
Cell Phone
Cell Phone
For the following questions, check YES or NO, whichever applies.
Are you in good health?
Has there been any change in your general health within the past year?
My last physical examination was on
My last physical examination was on
Are you now under the care of a physician?
Have you had any serious illness, operation, or been hospitalized in the past 5 years?
Do you have or have you had any of the following diseases or problems?
Cardiovascular disease (including heart trouble, heart attack, angina, coronary insufficiency, coronary occlusion, high blood pressure, arteriosclerosis, stroke)
Damaged heart valves or artificial heart valves (including heart murmur or rheumatic heart disease)
a. Do you have chest pain on exertion?
b. Are you ever short of breath after mild exercise or when lying down?
c. Do your ankles swell?
d. Do you have inborn heart defects?
e. Do you have a cardiac pacemaker?
Allergy
Sinus trouble
Asthma or hay fever
Fainting spells or seizures
Persistent diarrhea or recent weight loss
Diabetes
Hepatitis, jaundice or liver disease
Thyroid problems
Respiration problems, emphysema, bronchitis, etc
AIDS or HIV infection
Stomach ulcer or hyperacidity
Kidney trouble
Tuberculosis
Persistent cough or cough that produces blood
Persistent swollen glands in neck
Low blood pressure
Sexually transmitted disease
Epilepsy or other neurological disease
Problems with mental health
Cancer
Problem With Immune System
Have you had abnormal bleeding?
Have you ever required a blood transfusion?
Do you have any blood disorder?
Have you ever had any treatment for a tumor or growth?
Are you allergic or have you had a reaction to:
a. Local anesthetics
b. Penicillin or other antibiotics
c. Sulfa drugs
d. Barbiturates, sedatives, or sleeping pills
e. Aspirin
f. Iodine
g. Codeine or other narcotics
h. Other
Have you had any serious trouble associated with any previous dental treatment?
Do you have any disease, condition or problem not listed above that you think we should know about?
Are you wearing contact lenses?
Are you wearing removable dental appliances?
Do you smoke?
Do you drink alcoholic beverages?
For women only:
Are you pregnant?
Do you have any problems associated with your menstrual period?
Are you nursing?
Are you taking birth control pills?
Certification *
I certify that I have read and understood the above. I acknowledge that my questions, if any, about the 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 errors or omissions that I may have made in the completion of this form.
Help Notice
If you have any problems or questions regarding these forms, please call our office at 212.838.2900. We will be glad to assist you.