New Patient Form - Medical History

Patient First Name:
Patient Last Name:

Dentist: Please Select Dr. Andrew Doig Dr. Ryan Gallagher

1. Are you in Good Health
Yes No

2. Have you had an unusual reaction to drugs/medications? To what? i.e. Penicillin

Yes No

3. Is your physician treating you now?

Yes No

Reason?

4. Are you taking any medication? (prescription or over the counter)

Yes No
Please list
Pharmacy contact info

5. Do you smoke or use tobacco products?

Yes No

6. Do you use recreational medical marijuana?

Yes No

7. Do you have any allergies?

Yes No

Please list

8. Do you experience shortness of breath?

Yes No

9. Have you gained or lost excessive weight recently?

Yes No

10. Do you have heart disease or murmur? Heart Attack?

Yes No
If so, when?

11. Are your ankles often swollen?

Yes No

12. Have you ever had radiation treatment?

Yes No

13. For women only, are you any of the following?:

Pregnant

Nursing

HRT

14. Have you had any of the following? (check all that apply):

Heart trouble
High Blood Pressure
Rheumatic Fever
Blood disorders
Diabetes
Epilepsy
Thyroid trouble
Kidney trouble
Cancer
HIV/AIDS
Asthma
Tuberculosis
Pic Line
Anemia
STD
Hepatitis
Liver trouble

Other:

New Patient Form - General Inoformation

1. Birthday
January February March April May June July August September October November December 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905

2. Address

3. Postal Code

4. Home Phone

5. Work Phone

6. Cell Phone

7. Email

8. Health Card Number

9. Spouse/Parent Name

10. Employer/Occupation

11. Referred by:


This is to certifiy that I, undersigned, consent to the performing of the dental and oral surgery procedures agreed to be necessary or advisable, including the use of local anesthetic as indicated and i will assume responsibility for fees associated with those procedures. I acknowledge reviewing the College Park Dental privacy policy and understand my rights of privacy with respect to me (and any dependent children) personal information. I further consent to the collection, use and disclosure of my (or dependent child's) personal information;
(please check the boxes)

To provide dental services

To maintain communications with healthcare specialists and to provide me (us) with information and follow up respecting my dental care;

To communicate with my insurance plan(s) to facilitate the processing of my claims;

For the uses, purposes, and disclosures described in the privacy act.;

Dental Questionaire

1. Have you had any of the following?:

a. Orthodonic treatment (teeth straightened)

b. Surgery to teeth, jaws or face

c. Trauma to teeth, jaws or face

d. Periodontal (gum) treatment

2. Do you now or have you ever had sinus problems?

3. Have you ever had abnormal bleeding after an extraction or a cut?

4. Have you ever had a bad reaction to freezing or freezing that did not take?

5. Do you grind your teeth while awake or asleep?

6. Do you have any jaw joint problems: e.g. clicking, popping, pain?

7. Do you suffer from frequent headaches?

8. Are your teeth sensitive to hot or cold?

9. Are you satisfied with the appearance of your teeth?

Submit