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New Patient Forms

Save time at your first visit. Fill out your health history below, then download a ready-to-print PDF to bring with you. Nothing is submitted online — your information stays on your device and is only saved into the PDF you download.

For each health question, mark Y (yes), N (no), or ? (don't know). The columns are labeled Y / N / ? above each list.

1 Patient Information
2 Dental History & Symptoms
Are you currently experiencing dental pain or discomfort?

Check any that apply to you:

YN?YN?
Hard to open your mouth
Pain chewing, biting, or swallowing
Gums bleed when brushing or flossing
Had periodontal (gum) treatment
Sores or growths in your mouth
Clench or grind your teeth
Jaw clicks, pops, or hurts
Earaches or neck pains
Dental treatment makes you nervous
Serious injury to head or mouth
Problems with past dental treatment
Reaction to dental anesthesia
Sleep: mouth breathing
Sleep: snoring
Sleep: trouble breathing
Unhappy with your smile
3 Medications & Substances

Check any that apply, and add details below:

YN?YN?
Taking blood thinners (Coumadin, Warfarin, Xarelto, Plavix, aspirin, etc.)
Medication for osteoporosis or Paget's disease
IV medication for bone pain / cancer-related
Hormonal replacements
Use tobacco or nicotine products
Use vaping products
Use controlled substances (incl. marijuana)
4 Allergies

Check anything you are allergic to or have reacted to:

YN?YN?
Aspirin
Barbiturates / sedatives
Codeine / narcotics
Hay fever / seasonal
Iodine
Latex (rubber)
Local anesthetics
Metals
Penicillin / antibiotics
Sulfa drugs
5 Medical History

Check any that apply:

YN?YN?
I am in good physical health
Currently being treated by a physician
Advised to premedicate with antibiotics
Serious illness / surgery / hospitalized (past 5 yrs)
Joint replacement surgery
Heart valve replacement / heart surgery
Organ or bone marrow / stem cell transplant
Traveled internationally in last 30 days
Fever 100.4°F+ in last 72 hours
6 Medical Conditions

Check any condition you have or have been diagnosed with:

Heart & Circulatory

YN?YN?
Pacemaker / defibrillator
Artificial heart valve
Previous infective endocarditis
Congenital heart disease
Arteriosclerosis
Coronary artery disease
Congestive heart failure
Damaged heart valves
Heart attack
Heart murmur / rhythm disorder
Rheumatic heart disease
Stroke
High or low blood pressure
Anemia
Blood transfusion
Hemophilia

Respiratory & Neurological

YN?YN?
Asthma / COPD
Bronchitis
Emphysema
Sinus trouble
Tuberculosis
Anxiety
Depression
Epilepsy
Mental health disorder
Neurological disorder
Post-traumatic stress disorder
Brain injury / concussion
AIDS or HIV infection
Lupus

Other Conditions

YN?YN?
Cancer
Gastrointestinal disease
GERD / acid reflux
Stomach ulcers
Glaucoma
Arthritis
Chronic pain
Diabetes (Type I or II)
Eating disorder
Frequent infections
Hepatitis / jaundice / liver disease
Immune deficiency
Kidney problems
Malnutrition
Osteoporosis
Rheumatoid arthritis
Sexually transmitted infection
Thyroid problems
7 For Women
YN?YN?
Taking birth control pills
Pregnant
Nursing
8 Acknowledgment

I have answered the above questions completely and accurately to the best of my ability. I understand the practice may ask follow-up questions to ensure they have the information needed to treat me safely.

Tip: After downloading, open the PDF and print it, or save it to bring to your appointment. You can also email it to frontdesk@roveldental.com.

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