Dr. David F. Sutton, DMD, PA

NEW PATIENT FORM Every new patient that comes to see us is required to fill out a patient information form and a medical-dental history form. These forms can take 15 to 30 minutes to complete when they are filled out in our office. We are providing these forms on-line so that you can fill them in at your convenience and check on any information requested in case you aren't sure of an answer. Also, this will help us improve our service to you and reduce delays for your appointment. Please complete the form below, print it out and bring it with you for your first appointment. Please Complete All Fields Note: Use "TAB" Key and/or Pointer to Move Between Fields PATIENT INFORMATION Name: Married Single Minor Male Female Address: City: State: Zip: E-mail: Home Phone #: Date of Birth: How do you wish to be addressed: Legal guardian if minor: Name: Relationship: Address (if different from above): Phone: Employer: Address: City: State: Zip: Phone: Will you receive calls at work? Yes No Dental Insurance Company: Phone #: Address: City: State: Zip: Subscriber's Name: Subscriber's SSN: Patient's relationship to subscriber: Emergency Information Who may we call in case of an emergency? Name: Phone: Relationship: Address: Relative not living with you: Name: Phone: Relationship: Address: Medical-Dental History Patients Name: Last: First: MI: Male Female Date of Birth: The following information is required so that you may receive dental care that is compatible with your general health. Your cooperation in providing accurate information is necessary in order to meet your dental needs safely and efficiently. Incorrect information can endanger your health. Thank you. Name of Physician: Phone: Address: Date of last visit: Reason for last visit: Date of last physical exam: Are you currently under the care of a physician? Yes No If yes, for what reason or condition? Have you ever been hospitalized or had a major operation? Yes No If yes, for what reason or condition? Please list all medications you are currently taking. If none, write none. Do you have any alergies or sensitivities? Yes No Please click on the medications you have reacted to adversely or suffered an allergic reaction. Aspirin Motrin Codeine Tylenol Penicillin Tetracycline Erythromycin Local Anesthetic None Pleas list all other medications and substances to which you are allergic. If None, type in None. Have you ever had or been treated for . . . Rheumatic fever, heart murmur? Yes No Mitral valve prolapse, congenital heart lesions? Yes No Artificial heart valves,heart pacemaker, heart surgery?Yes No Heart attack, heart trouble, angina, irregular heart beats? Yes No High blood pressure, low blood pressure? Yes No Anemia, excessive bleeding, blood disorders, bruise easily? Yes No Ulcers, stomach or intestinal disease? Yes No Breathing problems, asthma, tuberculosis, hay fever? Yes No Diabetes? Yes No Hepatitis, jaundice, liver disease? Yes No Kidney problems or renal dialysis? Yes No Venereal disease, sexully transmitted disease? Yes No Chemotherapy or radiation treatments? Yes No Tumors, growths, or cancers? Yes No Fainting spells, convulsions, seizures, epilepsy? Yes No Strokes, CVA? Yes No Artificial joints (hip, knee)? Yes No Drug addiction, alcoholism? Yes No Thyroid disease? Yes No Arhtritis, rheumatism, lupus, auto-immune disorders? Yes No Psychiatric disorder? Yes No Blood transfusion? Yes No For women: Are you pregnant? Yes No Do you take birth control pills? Yes No Please list any disease or condition you have which is not described above: Dental History Name of previous dentist: Phone: Address: City: State: Zip: Last complete dental exam: Last full mouth X-rays date : Did you ever wear braces? Yes No Do you presently wear dentures or partials? Yes No Are you content with the way they look and/or fit? Yes No Have you had any periodontal/gum surgery? Yes No Are any of your teeth sensitive to heat, cold, sweets, pressure? Yes No Do you grind your teeth or clench your jaws? Yes No Do you have any pain or clicking in the jaw joint around your ear? Yes No Do your gums bleed, feel tender or irritatied? Yes No Have you ever had any abnormal bleeding, swelling or pain following dentatl treatment? Yes No Do you smoke, dip snuff or chew tobacco? Yes No Do you have any dental complaints? Yes No If so, please list them in the box below. Please click on your browser print button to make a copy of the form and bring it with you for your first appointment. Signature: _____________________________________________ Date: _________________________________________________