New Patient Intake Form

Who referred you to our office?*

Have you looked us up on

Washingtonian
Google
Dr. Oogle
Yelp
Other - Please Specify:

Name of Physician*

Physician Phone*

() -

Date of last physical exam*

Are you currently under physician care?*

Yes No
If yes for what?

Are you currently taking any medication (including supplements and vitamins)? *

Yes No

If yes, list medications and reasons for taking and indicate if you take it in AM or PM:

What is the reason for your visit?*

Do you have any specific concern regarding your visit or overall care?

»Do you have or have you had any of the following conditions?

Do you take any blood thinners*

Yes No

If yes, please list:

Has your doctor stated that you need to pre-medicate with antibiotics before dental visits?*

Yes No

Artificial/Damaged heart valves?*

Yes No

Congenital heart defect?*

Yes No

Prosthetic joint?*

Yes No

History of heart attack? Angina? Chest pain on exertion? Pacemaker? *

Yes No

High blood pressure? Do your ankles swell? Low blood pressure/dizziness?*

Yes No

Sinus problems?*

Yes No

Asthma? Other lung/breathing problems?*

Yes No

Diabetes or high glucose?*

Yes No

Date and result of most recent HbA1c

Hepatitis, jaundice, other liver dysfunction?*

Yes No

HIV?*

Yes No

Sexually-transmitted disease?*

Yes No

Thyroid problems? *

Yes No

Arthritis? Swollen joints?*

Yes No

Tuberculosis?*

Yes No

Persistent cough that produces blood?*

Yes No

Stomach ulcers or other Gastrointestinal problem?*

Yes No

Kidney problems?*

Yes No

Epilepsy or seizures?*

Yes No

Psychiatric care?*

Yes No
If yes, list Psychiatrist Name and Phone #

Cancer? *

Yes No

Low immune function?*

Yes No

Bleeding disorders?*

Yes No

Are you wearing contact lenses?*

Yes No

Do you have osteoporosis or osteopenia?*

Yes No

Do you smoke or use other forms of tobacco?*

Yes No
If yes, how many per day?

Our office offers IV Sedation (Twilight Sleep). Would you like to discuss this as an option?*

Yes No

Have you had any general surgeries?*

Yes No
If yes, please list:

Do you take or have you ever taken any bisphosphonate (i.e. Fosamax, Actonel, Boniva, etc)*

Yes No
If so, which one?

When was your last dental cleaning?*

How often do you have cleanings?*

Have you had any serious problems with dental treatment?*

Yes No
If so, please explain:

Do you have any medical disease or condition that is not listed?*

Yes No
If so, explain:

If you answered Yes to any of the above questions, please provide a brief history with relevant dates.

»Do you have an allergy to or have you had a bad reaction to:

Are there any medications you cannot or prefer not to take? *

Yes No

Local anesthetics (i.e. Novocain)*

Yes No

General anesthetics/sedation medication*

Yes No

Antibiotics*

Yes No

Sulfite (red wine )*

Yes No

Aspirin*

Yes No

Iodine*

Yes No

Codeine or other narcotics*

Yes No

Other medication allergies:

Are you, or do you think that you might be pregnant?

Yes No

Are you nursing?

Yes No

Do you take birth control pills?

Yes No

Do you have problems with your menstrual period?

Yes No

Do you take Viagra, Cialis or Levitra?

Yes No

I certify that I have read and understand the above. I acknowledge that my questions regarding this form have been answered to my satisfaction. I will not hold my dentist or any other member of the office staff responsible for errors or omissions that I may have made in the completion of this form. I acknowledge that if I make omissions or false statements, my health may be put at risk.

Signature of Patient or Patient's Representative *

Date*

Relationship to Patient (If not signed by the Patient)

»Financial Policy (View / Download this policy)

I certify that I have read and agree to the financial policy.

Signature of Patient or Patient's Representative *

Date*

»Photography Policy (View / Download this policy)

I understand that photography of my condition may be necessary and I authorize Dr. Puterman to take and utilize photographs as described. I understand that my privacy will be maintained and identifying features will not be shared.

Signature of Patient or Patient's Representative *

Date*

»Privacy Policy (View / Download this policy)

My signature acknowledges that I have been provided with a copy of the Notice of Privacy Practices.