Dr. David F. Sutton, DMD, PA


Services

Procedures

Insurance

Privacy

New Patients

Staff

Map

Links Collection

Line

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

Line

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 PRINT to make a copy of this form and bring it with you for your first appointment.

Signature: _____________________________________________

Date: _________________________________________________

Line

This site created and maintained by Sparrow & Finch, Inc.

© 1997-2016 Sparrow & Finch, Inc.