mcbride@rpmdentistry.com
562.421.3747
Form: Denture New Patient Info

Form: Denture New Patient Info



Patient Information















Personal History

MarriedSingleWidowedDivorced













YesNo

Medical History

The thoroughness of this medical history is designed for your safety, and your complete answers will assist us in treating you with consideration for your special needs.























Please check YES or NO.

YesNo



YesNo

YesNo

YesNo

Angina (chest pains) Rheumatic Fever
Heart Attack Heart Murmur  
Heart Surgery High Blood Pressure  
Pacemaker   Low Blood Pressure  
Bypass   Congenital Heart lesions  
Prosthetic heart valve   Atherosclerosis  
Stroke Other:
Blood Pressure    

YesNo

YesNo


YesNo

YesNo

YesNo

DietOral MedicationInjections

YesNo

YesNo

YesNo

Type A Infectious (Food) Type B Serum (Blood)

Type C (non-A, non-B) Unknown

YesNo

YesNo

Anemia AIDS or HIV positive test Leukemia Venereal disease

Other:

YesNo

YesNo

YesNo

YesNo

YesNo

YesNo

Rheumatoid Arthritis Gout/Gouty Arthritis Osteoarthritis Other



YesNo



YesNo

YesNo

YesNo

Right eyeLeft eyeBoth eyes

Have you gained or lost weight within the last year?


YesNo

YesNo

YesNo

YesNo

YesNo

YesNo

YesNo

YesNo

YesNo

Questions 35-36 are For Women Only

YesNo

YesNo

YesNo

Penicillin   Local anesthetics  
Erythromycin   Novocaine  
Sulfa Drugs   Xylocaine  
Codeine   Nitrous Oxide  
Aspirin   Epinephrine  
Sleeping Pills   Other pain medications:
Barbiturates      
Antibiotics Any other drug allergies?

YesNo

YesNo

YesNo

YesNo


YesNo

Please indicate if you are taking any of the following medications:

 
Heart Medication
Blood Pressure Medication
Cholesterol lowering
Insulin
Nitroglycerine
Blood Thinner Medication
Antibiotics
Sedatives
Tranquilizers
Anti Depressants
Pain Medication
Cortisone (Steroids)
Thyroid
Birth Control Pills
Over Counter Medications
Medicinal Patches
Other:

Alcohol

Tobacco

YesNo



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